Form CFS604 "Medical Evaluation of an Adult in a Foster or Adoptive Home" - Illinois

What Is Form CFS604?

This is a legal form that was released by the Illinois Department of Children and Family Services - a government authority operating within Illinois. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2020;
  • The latest edition provided by the Illinois Department of Children and Family Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CFS604 by clicking the link below or browse more documents and templates provided by the Illinois Department of Children and Family Services.

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Download Form CFS604 "Medical Evaluation of an Adult in a Foster or Adoptive Home" - Illinois

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Form Distribution
CFS 604
Licensing worker/supervisor
STATE OF ILLINOIS
Rev. 8/2020
Kept in a sealed envelop in the
DEPARTMENT OF CHILDREN AND FAMILY SERVICES
licensing file and marked
“CONFIDENTIAL”
Medical Evaluation of an Adult in a Foster or Adoptive Home
Name of Person Examined:
Date:
Date of Birth:
How long have you been treating this patient?
This form will aid the Department in determining the physical wellness and capabilities of adults in foster or
adoptive homes who are or may be caring for children. Please complete the following summary of health
problems, conditions, and medication use that may affect the adult’s ability to maintain alertness, endurance,
and performance of tasks and responsibilities associated with caring for up to six children, ages 0 to 18 now
and for the foreseeable future (five to ten years).
I. HISTORY
1. Check any health problems:
Heart Problems
Arthritis
Depression
Tremors
Lung Problems
Obesity
Sleep Disorder
Hepatitis
Diabetes
Poor Ambulation
Confusion
Allergies
High Blood Pressure
Weak/Frail
Dementia
Asthma
Vision
Epilepsy/Seizures
Kidney Disease
Hearing
Strokes/Paralysis
Explain all medical condition(s) checked and any other chronic conditions:
2. Are there any condition(s) that are progressive in nature? Yes
No
If yes, explain:
3. Is there a terminal illness that could interfere with this person’s ability to care for a child in the next ___5 years, ___10 years
__15 years? If yes, explain:
4. Medication(s):
Are there any physical limitations as a result of medication(s)? Yes
No
If yes, explain:
4. Illness/Injuries, Operations or Hospitalizations during the last 5 years:
Illness/Injury
Operation
Hospitalization
Date
Outcome
5. Health Habits
Is there a history of substances used by the applicant and what degree of impairment exists, if any, from the substance use?
Alcohol
Drugs
Tobacco
Other
Form Distribution
CFS 604
Licensing worker/supervisor
STATE OF ILLINOIS
Rev. 8/2020
Kept in a sealed envelop in the
DEPARTMENT OF CHILDREN AND FAMILY SERVICES
licensing file and marked
“CONFIDENTIAL”
Medical Evaluation of an Adult in a Foster or Adoptive Home
Name of Person Examined:
Date:
Date of Birth:
How long have you been treating this patient?
This form will aid the Department in determining the physical wellness and capabilities of adults in foster or
adoptive homes who are or may be caring for children. Please complete the following summary of health
problems, conditions, and medication use that may affect the adult’s ability to maintain alertness, endurance,
and performance of tasks and responsibilities associated with caring for up to six children, ages 0 to 18 now
and for the foreseeable future (five to ten years).
I. HISTORY
1. Check any health problems:
Heart Problems
Arthritis
Depression
Tremors
Lung Problems
Obesity
Sleep Disorder
Hepatitis
Diabetes
Poor Ambulation
Confusion
Allergies
High Blood Pressure
Weak/Frail
Dementia
Asthma
Vision
Epilepsy/Seizures
Kidney Disease
Hearing
Strokes/Paralysis
Explain all medical condition(s) checked and any other chronic conditions:
2. Are there any condition(s) that are progressive in nature? Yes
No
If yes, explain:
3. Is there a terminal illness that could interfere with this person’s ability to care for a child in the next ___5 years, ___10 years
__15 years? If yes, explain:
4. Medication(s):
Are there any physical limitations as a result of medication(s)? Yes
No
If yes, explain:
4. Illness/Injuries, Operations or Hospitalizations during the last 5 years:
Illness/Injury
Operation
Hospitalization
Date
Outcome
5. Health Habits
Is there a history of substances used by the applicant and what degree of impairment exists, if any, from the substance use?
Alcohol
Drugs
Tobacco
Other
6. Date
Result of Tuberculin Test (initial exam only):
7. Date
Result of Chest X-Ray (if necessary):
II. IMMUNIZATIONS
Has the patient received the following immunization?
Tdap:
YES
Date Received:
NO
Reason:
Has the patient received a flu vaccination over the past year?
NO – Reason:
YES - Date Received
III. PHYSICAL EXAMINATION
Summary of abnormal physical findings that would affect caring for a child:
IV. PHYSICAL CAPABILITIES
In your medical opinion could your patient physically be able to:
1.
Lift a child:
Under 6 months
Yes
No
6 months to 3 years
Yes
No
2.
Walk/maneuver 50-100 feet without major difficulties: Yes
No
3.
Bend/stoop, kneel, reach: Yes
No
4.
Is an assistive device needed to walk, bend/stoop, kneel, or reach? Yes
No
If Yes, what type?
Are there any medical conditions which limit this person’s physical ability to care for a medically complex child
5.
which may include the ability to:
Don’t Know
Lift from a bed to chair, etc.
Yes
No
Don’t Know
Frequent Feedings
Yes
No
Don’t Know
Frequent Suctions
Yes
No
Don’t Know
Frequent Monitoring
Yes
No
Don’t Know
Frequent Medication
Yes
No
Don’t Know
Frequent Nebulizations
Yes
No
Don’t Know
Frequent Treatments
Yes
No
Are any limiting conditions temporary?
Yes
No
If yes, which condition(s):
For each condition, how long will the limitation exist?
I certify that this individual is found free from symptoms of communicable disease.
Yes
No
If No, explain:
I certify that the individual has no physical or cognitive limitations that would prevent her/him from parenting.
Yes
No
If No, explain:
Physician’s Signature:
Date:
State License Number:
Address:
Telephone:
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