ODHS 1653 (9/96), Page 1 of 2 MEDICAL STATEMENT FOR FOSTER CARE/ADOPTIVE APPLICANT AND ALL HOUSEHOLD MEMBERS Name (LAST, FIRST, MIDDLE) Date of Birth Address (Street, City, State and ZIP) 1. Have you had treatment for a serious or chronic illness? . o YES o NO Have you been hospitalized in the past five years? . o YES o NO Have you ever received, or been advised to seek, menta1 health services? o YES o NO Have you ever received, or been advised to seek, treatment for alcohol/substance abuse? .. o YES o NO If the answer to any of these questions is yes, please explain: 2. Have you or your parents, grandparents, or siblings had any of the follo wing? (Check all that apply and indicate whom) o Arthritis o Heart Disease o Asthma o Hypertension o Cancer o Kidney Disease o Epilepsy o Tuberculosis o Diabetes o Ulcers If any are checked, please explain: 3. Is there a history of other hereditary disease? .. o YES o NO If yes, please explain: AUTHORIZATION FOR RELEASE OF INFORMATION I hereby affirm that I have completed this form to the best of my ability, and that the information provided is true and correct. I further authorize the physician completing the reverse side of this form to release any information he/she may have concerning my physical or mental health to: (Name of Agency) Signature of Applicant Date COMPLETION OF THIS FORM IS REQUIRED FOR THE AGENCY TO PROCEED WITH YOUR APPLICATION. DHS 1653 (9/96) American LegalNet, Inc. www.USCourtForms.com >>>> 2MEDICAL STATEMENT FOR FOSTER CARE/ADOPTIVE APPLICANT AND ALL HOUSEHOLD MEMBERS (Continued) ODHS 1653 (9/96), Page 2 of 2 (This side of form to be completed by a licensed physician) Date you last completed a physical Date you last examination of this individual: treated this individual: Do you provide medical services to this individual: o Regularly o Occasionally o First Time Please respond to each of the following to the best of your knowledge: 1. Does this individual suffer from an illness, including a communicable di sease, that would be detrimental to the care of a foster/adoptive child placed in his/her hom e? o YES o NO 2. Are there any chronic or serious disorders for which this individual has received treatment?. o YES o NO 3. Is this individual currently taking medication? ... o YES o NO 4. Is this individual experiencing any physical, behavioral or emotional problems that would be detrimental to a foster/adoptive child placed in his/her home? .. o YES o NO 5. Have you ever referred this individual to other medical services, mental health services or treatment for alcohol/substance abuse? ... o YES o NO If the answer to any of the above questions is YES, please explain: (For foster/adoptive applicant only, please complete.) Please state your professional opinion regarding this individuals suitabil ity as a foster/adoptive parent from the standpoint of health, considering the individuals medical history as given on the reverse sid e of this form and from knowledge you have of the individual. Physicians Signature: Date Name of Physician (Print or Type): Physicians Work Address: Physicians Work Physicians Phone Number: State License Number: NOTE: Completion of this form is required pursuant to Ohio Administrative Code Rules 5101:2-5-20 or 5101:2-48-07. DHS 1653 (9/96) American LegalNet, Inc. www.USCourtForms.com