Form AD524 (BI) "Physician's Examination of Adoption Applicant/Petitioner" - California

What Is Form AD524 (BI)?

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

Form Details:

  • Released on March 1, 1999;
  • The latest edition provided by the California Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form AD524 (BI) by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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Download Form AD524 (BI) "Physician's Examination of Adoption Applicant/Petitioner" - California

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PHYSICIAN'S EXAMINATION OF ADOPTION APPLICANT/PETITIONER
PATIENT’S NAME
PATIENT’S SIGNATURE
DATE
I hereby authorize Dr.______________________________________, to release the medical information contained on this form to
the_________________________________________(insert name of licensed adoption agency or CDSS Adoptions Branch District Office)
for the purpose of investigating the adoptive placement of a child.
Por este medio autorizo al Dr._____________________________ para que comparta la información médica contenida en este formulario
con _________________________________________ (escriba el nombre de la oficina/agencia de adopciones certificada o de la Oficina de
Distrito correspondiente a la Oficina Central de Adopciones del Departamento de Servicios Sociales de California) para el propósito de
investigar la colocación del niño en adopción.
I. MEDICAL HISTORY
Check if condition is present and provide comment
Mental Illness
Cancer
Ulcers
Impaired Hearing (Extent)
Hypertension
Heart Disease
Impaired Sight (Extent)
Allergies
Neurosis
Any Surgical Operations
Diabetes
Epilepsy
Speech Defects (Describe)
Arthritis
Venereal Disease
Orthopedic Defects
Tuberculosis
Depression
Chemical Dependence
Other Medical Condition
History of Hereditary Disease or Abnormality
Comments:_______________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
II. PHYSICAL EXAMINATION
Height ____________
Weight ______________
____________________________ Eyes
____________________________ TB Test (Date & Finding)
____________________________ Ear, Nose, Throat
____________________________ Cholesterol Reading
____________________________ Heart
____________________________ Blood Pressure Reading
____________________________ Lungs
____________________________ Urinalysis (Date/Finding)
____________________________ Pelvic
____________________________ Genito-Urinary
____________________________ Abdominal
III. ABILITY TO HAVE OWN CHILD
Has the patient been under treatment for infertility/sterility? ....................................................................................
YES
NO
If infertility/sterility exists, has the medical basis been determined? ........................................................................
YES
NO
If YES, give results of studies: _______________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
With proper treatment, would impregnation be possible? ........................................................................................
YES
NO
AD 524 (BI) (3/99)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PHYSICIAN'S EXAMINATION OF ADOPTION APPLICANT/PETITIONER
PATIENT’S NAME
PATIENT’S SIGNATURE
DATE
I hereby authorize Dr.______________________________________, to release the medical information contained on this form to
the_________________________________________(insert name of licensed adoption agency or CDSS Adoptions Branch District Office)
for the purpose of investigating the adoptive placement of a child.
Por este medio autorizo al Dr._____________________________ para que comparta la información médica contenida en este formulario
con _________________________________________ (escriba el nombre de la oficina/agencia de adopciones certificada o de la Oficina de
Distrito correspondiente a la Oficina Central de Adopciones del Departamento de Servicios Sociales de California) para el propósito de
investigar la colocación del niño en adopción.
I. MEDICAL HISTORY
Check if condition is present and provide comment
Mental Illness
Cancer
Ulcers
Impaired Hearing (Extent)
Hypertension
Heart Disease
Impaired Sight (Extent)
Allergies
Neurosis
Any Surgical Operations
Diabetes
Epilepsy
Speech Defects (Describe)
Arthritis
Venereal Disease
Orthopedic Defects
Tuberculosis
Depression
Chemical Dependence
Other Medical Condition
History of Hereditary Disease or Abnormality
Comments:_______________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
II. PHYSICAL EXAMINATION
Height ____________
Weight ______________
____________________________ Eyes
____________________________ TB Test (Date & Finding)
____________________________ Ear, Nose, Throat
____________________________ Cholesterol Reading
____________________________ Heart
____________________________ Blood Pressure Reading
____________________________ Lungs
____________________________ Urinalysis (Date/Finding)
____________________________ Pelvic
____________________________ Genito-Urinary
____________________________ Abdominal
III. ABILITY TO HAVE OWN CHILD
Has the patient been under treatment for infertility/sterility? ....................................................................................
YES
NO
If infertility/sterility exists, has the medical basis been determined? ........................................................................
YES
NO
If YES, give results of studies: _______________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
With proper treatment, would impregnation be possible? ........................................................................................
YES
NO
AD 524 (BI) (3/99)
IV. GENERAL HEALTH AND PHYSICAL CONDITION
What medication(s) is patient currently taking?
What medication(s) has been prescribed in the recent past?
Is there any organic or functional disorder that would affect the patient’s life expectancy or ability to function
as a parent? ......................................................................................................................................................................
YES
NO
If YES, please elaborate:
How long have you known the patient?____________________________________________________________________________
From a medical viewpoint, would you recommend this patient as an adoptive parent?....................................................
YES
NO
If NO, please elaborate:
Based on your knowledge and observations of the patient, how would you assess his/her adjustment to this adoptive placement?
EXCELLENT
GOOD
FAIR
QUESTIONABLE
DON’T KNOW
Please use this space for any additional comments: _____________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
DATE EXAMINED
SIGNATURE OF DOCTOR
ADDRESS OF DOCTOR
TELEPHONE NUMBER
TYPED NAME OF DOCTOR
Please mail directly to:
AD 524 (BI) (3/99)
OPTIONAL HIV TEST AND DISCLOSURE AUTHORIZATION
The HIV test and authorization to disclose the results of the test are optional and intended only for patients who wish to submit to, or have
undergone, a blood test for antibodies to the probative causative agent of acquired immune deficiency syndrome (AIDS) and choose to
have their health care provider disclose the results of the test in accordance with Health and Safety Code Section 199.21 (g).
I hereby authorize Dr._______________________to release results of an HIV test to (1)____________________________________(insert
name of licensed adoption agency or CDSS Adoptions Branch District Office) for the purpose of investigating the adoptive placement of a
child and (2) the______________________________County Superior Court for the purpose of the adoption proceeding.
PATIENT’S SIGNATURE
DATE
PRUEBA OPCIONAL DEL VIH* Y AUTORIZACION OPCIONAL PARA COMPARTIR INFORMACION
La prueba del VIH y la autorización para compartir los resultados de la prueba son opcionales y solamente son pertinentes a los pacientes
que deseen someterse, o que ya se hayan sometido, a un análisis de sangre para detectar anticuerpos del agente que se ha probado es la
causa del SIDA**, y estas personas eligen que su proveedor de cuidado de la salud comparta los resultados de la prueba, en conformidad
con la sección 199.21 (g) del Código de Salud y Seguridad.
Por este medio autorizo al Dr.
para que comparta los resultados de la prueba del VIH con
(1)_____________________________________ (escriba el nombre de la oficina/agencia de adopciones certificada o de la Oficina de Distrito
correspondiente a la Oficina Central de Adopciones del Departamento de Servicios Sociales de California) para el propósito de investigar la
colocación del niño en adopción y (2) la Corte Superior del Condado de ______________________________ para fines del trámite de adopción.
FIRMA DEL PACIENTE
FECHA
HIV TEST RESULTS
(DATE OF TEST AND FINDING)
SIGNATURE OF DOCTOR
DATE
ADDRESS OF DOCTOR
TYPED NAME OF DOCTOR
TELEPHONE NUMBER
SEND RESULTS TO:
*virus de inmunodeficiencia humana
**síndrome de inmunodeficiencia adquirida
AD 524 (BI) (3/99)
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