Foster Care Manual: Foster Child Annual Physical Examination

This form is filled out by the doctor when he does a physical on your child. This is required as soon as possible after your child arrives in your home (some areas require it in 24hrs). This physical is done every year; babies may have different requirements (e.g. every 6 months). Also if you have a medical needs child, the physical may be performed more frequently.


Client Annual Physical Examination


Client:_____________________________________


Attention Physican:
The following items are required by the State to be
included in all annual physical examinations.
Thank you for your assistance.


A review of previous health history:______________

___________________________________________

___________________________________________


A general physical examination.
List any abnormalities:
(Clients over the age of 18 need an annual gynocological exam)

___________________________________________

Height:___________Weight:__________


Immunizations
as recommended by the U.S. Public Health Services:


Please list date of last DT booster.

__________________________________________


Vision and Hearing screening:________________

_________________________________________


Any special instructions for resident’s diet:________

__________________________________________


Age appropriate screening tests for clients under age 18,
according to the standards of the American Academy of Pediatrics.

__________________________________________


Any medical information pertinent to diagnosis
and treatment in case of emergency:

___________________________________________

___________________________________________


Physician signature:________________ Date:______


Name:______________________________________

Address:____________________________________


Telephone number:_______________