ࡱ> '` bjbj{P{P .::6T  ^^^8R^t^ t`eeeefmhii}$$&h iffii eelqpqpqpiX e e}qpi}qpqp qpe` е`^Ajqp3qd 0qpj8qp piiqpiiiiipXiiiiiii 3<$! <  MEDICAL STATEMENT FOR FOSTER HOME LICENSING/ADOPTION(For Applicant and all Household members)Michigan Department of Human ServicesFamily NameDate FORMTEXT       FORMTEXT      Patient Information (to be completed by patient or responsible adult)NameRelationship to ApplicantDate of Birth FORMTEXT       FORMTEXT       FORMTEXT      Address (Street, City, State, Zip) FORMTEXT      Are you currently taking any medication? If yes, please list medications and reason for use. FORMTEXT       FORMTEXT       FORMTEXT      Have you ever been treated for any of the following? (Check all that apply) FORMCHECKBOX Heart Disease FORMCHECKBOX Kidney Disease FORMCHECKBOX Cancer FORMCHECKBOX Diabetes FORMCHECKBOX Emphysema FORMCHECKBOX Epilepsy FORMCHECKBOX Tuberculosis FORMCHECKBOX Alcohol Abuse FORMCHECKBOX Substance Abuse FORMCHECKBOX Mental Health Issues FORMCHECKBOX Current Communicable Disease FORMCHECKBOX Other serious or chronic illnessIf any are checked, please explain: FORMTEXT       FORMTEXT       FORMTEXT      If you have checked any of the above, please have page 2 of this form completed by your licensed physician, physician s assistant or nurse practitioner.If you have not checked any of the above, please have your licensed physician, physicians assistant or nurse practitioner read and sign the following statement:MEDICAL PRACTITIONERS STATEMENTIn your opinion, are there any physical or mental factors that would jeopardize the physical or mental welfare of any child placed in this family for foster care or adoption?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoPractitioners SignatureDatePractitioners printed name FORMTEXT       FORMTEXT      AddressTelephone Number FORMTEXT      ( FORMTEXT    )  FORMTEXT      AUTHORIZATION FOR RELEASE OF INFORMATIONI hereby authorize my health care professional to release to the Michigan Department of Human Services or its agents information regarding my physical condition, mental health, and/or substance abuse services. I understand that completion of this form is required for the agency to proceed with the adoption/foster home licensing process.Patient or Responsible Adult Signature and Date PHYSICAL EXAMINATIONMichigan Department of Human ServicesNameDate of Birth FORMTEXT       FORMTEXT      TO BE COMPLETED BY LICENSED PHYSICIAN, PHYSICIAN S ASSISTANT OR NURSE PRACTITIONERDate of physical examinationDo you provide medical services to this individual: FORMTEXT       FORMCHECKBOX Regularly FORMCHECKBOX Occasionally FORMCHECKBOX First timePlease respond to the following to the best of your knowledge:1.Does this individual suffer from an illness including a communicable disease that would be detrimentalto the care of a foster child/adoptive child placed in his/her home? FORMCHECKBOX Yes FORMCHECKBOX No2.Are there any chronic or serious disorders for which this individual has been or is receiving treatment? FORMCHECKBOX Yes FORMCHECKBOX No3.Is this individual currently taking medication? FORMCHECKBOX Yes FORMCHECKBOX No4.If yes, could this medication adversely effect his/her ability to care for or be around children? FORMCHECKBOX Yes FORMCHECKBOX No5.Has this individual been tested for TB? 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FORMCHECKBOX Yes FORMCHECKBOX No7.Have you ever referred this individual to other medical services, mental health services or treatment ofalcohol/substance abuse? FORMCHECKBOX Yes FORMCHECKBOX NoIf the answer to any of the above questions is YES, please explain:Height FORMTEXT      Weight FORMTEXT      Heart FORMTEXT      Blood Pressure FORMTEXT      Lungs FORMTEXT      Vision FORMTEXT      Hearing FORMTEXT      General Appearance FORMTEXT      LABORATORY TESTS:Tuberculin Test and/or X-RayDate FORMTEXT      Results FORMTEXT      HemoglobinDate FORMTEXT      Results FORMTEXT      UrinalysisDate FORMTEXT      Results FORMTEXT      PHYSICIAN S REMARKS ON HISTORY FORMTEXT       FORMTEXT      PRACTITIONER S STATEMENTIn your opinion, are there any physical or mental factors that would jeopardize the physical or mental welfare of any child placed in this family for foster care and/or adoption? FORMCHECKBOX Yes FORMCHECKBOX NoWould you like to be contacted by the foster home licensing/adoption worker regarding your recommendation? FORMCHECKBOX Yes FORMCHECKBOX NoPractitioner s SignatureDatePractitioner s Printed NameLicense Number FORMTEXT       FORMTEXT       FORMTEXT      AddressTelephone Number FORMTEXT       FORMTEXT      FORMTEXT           DHS-3190 (Rev. 6-10) Previous edition may be used. 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