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Adoption Medical History Form
Medical History

Adoption Medical History Form

2 pages•16 fields•HIPAA-ready
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Adoption Medical History Form
Adopted Child Name
Date of Birth
Country of Birth
Known Birth Parent Health Conditions
Prenatal Exposure History
Diabetes
Hypertension
Asthma
Heart Disease
Age at Adoption
Immunization Records Available
Developmental Milestones
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This adoption medical history form is designed to capture all available health information for adopted individuals, recognizing the unique challenges of incomplete family medical histories. The form systematically documents known birth parent health conditions, prenatal exposures, delivery complications, and early developmental milestones. It includes sections for international adoption-specific concerns such as immunization verification, infectious disease screening, and nutritional deficiencies common in institutional care settings.

Valuable for adoption agencies, pediatricians, family medicine practices, and international adoption medical clinics. The form helps healthcare providers identify potential genetic risks, assess developmental delays, and plan appropriate screening protocols when family history is limited or unknown. It documents country of origin health risks, available genetic testing, foster care history, and any known substance exposures during pregnancy.

What's included

  • Available birth parent health information
  • Prenatal and delivery history
  • Country of origin and ethnicity
  • Immunization verification needs
  • Developmental milestone documentation
  • Foster care or institutional history
  • Known prenatal substance exposures
  • Infectious disease screening results
  • Growth parameters at adoption
  • Genetic testing recommendations

Who uses this template

  • Adoption Agencies
  • Pediatric Practices
  • International Adoption Clinics
  • Family Medicine Offices
  • Developmental Pediatrics

All form fields

8 fields across 2 pages. Customize any field after signing up.

Adopted Child NameText
Date of BirthDate
Country of BirthText
Known Birth Parent Health ConditionsLong Text
Prenatal Exposure HistoryConditions
Age at AdoptionText
Immunization Records AvailableMultiple Choice
Developmental MilestonesLong Text

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