CHILD CARE PLAN

1. That, I am/ we are the designating the following person/s to act custodian/s of our
child/ren in case or death, absence, or in capacity to act/perform our parenting roles
and responsibilities:

Name Date/s of Address Relationship to Occupation/

Birth PAPs Income
1.
2.
3.

2. That I/We chose the above person/s because of ________________________________.

3. That, he /she/they is /are morally sound and financially capable to act as temporary
custodian/s of the child to be adopted.

Signature

____________________________ ____________________________
Male PAP Female PAP
Date Signed: __________________ Date Signed: __________________

ACKNOWLEDGEMENT
That I/We/am/are accepting the designation to be the temporary custodian/s of the adoptive
child of Mr./Mrs./Ms. _____________________.
Signature:
Date Signed:
1. ___________________ and ___________________ ___________________
2. ___________________ and ___________________ ___________________
3. ___________________ and ___________________ ___________________
 HEALTH AND MEDICAL PROFILE
(Should be typewritten or legibly/written printed. All blanks must be properly filled-up. Please indicate N/A if not applicable)

I. CHILD IDENTIFICATION

Name of Child: ______________________ DOB: ___________ Age: _______ Sex: ______

Date of Admission: _____________ Age upon Admission: _______ Status: ___________
Present Address: ___________________________________________________________

Information upon admission:

Weight: ____ kgs. Head Circumference: ______ cms.
Length/Height ____ cms. Chest Circumference: ______ cms.
Abdominal Circumference: ______ cms.

Distinguishing marks or Physical Handicaps (if any):

_________________________________________________________________________
_________________________________________________________________________

II. PHYSICAL DESCRIPTION AND CONDITION

Describe appearance of the child at the time of admission to the agency/institution of care:
(Avoid infographic details)
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Describe present appearance:

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

GROWTH RECORD
(Record should start from date of admission)

Year/ Age in Weight Ideal Length HC CC Remarks

Month Months (in Kgs) Body (in cms) (cms) (cms)
Weight

Is there any evidence of disease, impairment or abnormality of?

YES NO OBSERVATION
Head
Eyes
Nose
Ears
Mouth and Throat
Neck
Chest (Heart/Respiration)
 Abdomen
External Genitalia
Back/Spinal Column
Limbs/Extremities
Nervous System
Skin

III. BIRTH HISTORY

Age of Gestation: ____ wks (___ Full Term ___ Premature)

Type of Delivery: ____ Normal Place of Delivery: ____ Home

____ Caesarean Section ____ Hospital
____ Forceps ____ Others
(specify: ________)

Birth Attendant: ____ Doctor

____ Nurse
____ Professional Midwife
____ “Hilot”

APGAR Score: ________ Head Circumference: ________ cms

Birth weight: ________ kgs Chest Circumference: ________ cms
Birth Length: ________ cms Abdominal Circumference: ________ cms

Abnormalities at birth, if any (Pls. describe)

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

History of Sexually Transmitted Infection/Disease (if applicable)

Specify the infection/disease and treatments: ____________________________________

Any symptoms of Hepatitis B? ________________________________________________

Result of Tests for:
Hbs Ag (date and year): __________
Anti-HBs (date and year): __________
HBeAg (date and year): __________
Anti HBe (date and year): __________

Any history of Jaundice and blood transfusion? ___________________________________

Further tests/ treatment undertaken:

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Newborn Screening Result:

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Result of:
 Hearing test: _____
Eye test: ____

IMMUNIZATION RECORD:

Vaccine Date Administered Where Administered

BCG
DPT
1
2
3
OPV
1
2
3
Measles
HIB
1
2
Hepatitis B
1
2
3
Other Vaccines Given
a.
b.
c.

IV. RECORDS OF MEDICAL PROBLEMS/HOSPITALIZATION/

ILLNESSES/ ACCIDENTS/ SURGERIES:

Date/Age Medical Illness Laboratory Test Medication Remarks

Done/ Test Given and (Indicate if on-going
Results Dosage or resolved or any
complication(s) that
ensued)

V. OTHER MEDICAL CONCERNS

Specific Medical Condition/Other Diagnosis:

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Is the child in medication? ____
If yes, please indicate prescription (dosage, etc.)
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
 Describe any allergies (medication, food, etc.) present, if any.
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Special Diet, if applicable:

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Good ___
Fair ___
Poor ___

Remarks:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

VI. HABITS

Enuresis: ____
Thumb Sucking: ____
Masturbation: ____
Nail Biting: ____
Others/Remarks: ________________

VII. NOTES/RECOMMENDATIONS
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Completed by:

NURSE:
Date: _________________

Assessed by:

_______________________________
Doctor’s Signature Over Printed Name
Pediatrician/Family Physician
License No. ________ PTR No. ______

_________________________________
HOSPITAL/CLINIC
 MEDICAL EVALUATION FORM
(Kindly fill all blanks LEGIBLY)

Applicant: ____________________________________ Age: ________ Sex: ___________

Address: _________________________________________________________________
Name of Physician: _________________________________________________________
Date/s of Examination: ______________________________

MEDICAL HISTORY OF APPLICANT:

Describe the person’s general physical health:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Does he/she have a history of hereditary disease or congenital abnormality? If there is/are,
what is/are this/these?
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Does applicant have any history of the following? If yes, please describe:

Tuberculosis: ______________________________________________________________
Epilepsy : _________________________________________________________________
Asthma: __________________________________________________________________
Mental Illness: _____________________________________________________________
Nervous Disorders/Neuroses: _________________________________________________
Cancer: __________________________________________________________________
Venereal Disease: __________________________________________________________
Allergies: _________________________________________________________________
Glandular/Hormonal/Enzymatic Disturbance (Specify): _____________________________
_________________________________________________________________________
Serious Illness: ____________________________________________________________
Surgery: _________________________________________________________________
Handicaps: _______________________________________________________________
Impaired Sight (Extent: ______________________________________________________
Defective Hearing (Extent): ___________________________________________________
Speech Defects (Describe): ___________________________________________________
List any Psychotherapy/Counseling Utilized (Date, reason, prognosis)__________________
_________________________________________________________________________
Others (describe): __________________________________________________________
_________________________________________________________________________

PHYSICAL EXAMINATION OF APPLICANT:

Eyes: ________________ Heart: ____________________ Ears: ____________________
Lungs: _______________ Height: ___________________ Nose: ____________________
Abdomen: ____________ Weight: ___________________ Throat: ___________________
Spine: _______________ Skin: _____________________

EXAMINATION/TEST/S GIVEN TO APPLICANT:

Blood Pressure (Date and Findings): ____________________________________________
Urinalysis (Date and Findings): ________________________________________________
Serology for Syphilis (Date and Findings): _______________________________________
Chest X-ray (Date and Findings): ______________________________________________
Is there a history of miscarriage or stillbirth (Give dates, etc.)?
_________________________________________________________________________
Reason for infertility (if yes, please specify)
_________________________________________________________________________
_________________________________________________________________________

Is there any health condition which would render the applicant unable to give proper care to
a child/adoptee and would affect the stability of the home situation in the future?
_________________________________________________________________________
_________________________________________________________________________

Based on your overall assessment of the health of the applicant, is/are there any reason/s
for you not to recommend the applicant as a prospective adoptive parent?
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

______________________________ ____________________________
Signature of the Examining Physician Name of the Physician

______________________________ ____________________________
License Number and Validity Date