The two Forms: Financial Status and Physical Examination

(From CCAA's Revision of Dec. 4, 2000, effective Feb. 1, 2001)

The forms are required by the Homestudy/Dossier Guidelines.

The Financial Status form is referred to as Form 1.
Form 2 is the Physical Examination form and is seen below, following Form 1.
Presented here by China Connection.

[Form is effective Feb.1, 2001]

 

CERTIFICATE OF FINANCIAL STATUS

 

 

APPLICANTS' NAMES

 

 

                                                                       This year                             Last year

Annual Income: self/husband:

                           Self/wife:

 

Other Annual Income: self/husband:

                                     Self/wife:

 

Life Insurance:     self/husband:

                             Self/Wife:

 

Assets:                                                                          Value

      Personal Property (vehicles and others)

      Real Estate (Residence and others)

      Stocks and bonds

      Savings Account

      Checking Account

      Other Investment

 

Total Assets (Not including annual income & insurance):

 

 

Liabilities:                       Monthly Payment         Total Owed

 

        Credit Cards

        Home Mortgage

        Other Liabilities

 

Total Liabilities:

 

 

Net Worth:

 

 

I/We attest that the above-mentioned financial statement is an accurate summary
of my/our assets, liabilities and others.

 

     Signature                                                               Signature

 

 

 

 

 

_________________________________________________________

[Before going for the physical examination, parents should refer to the points under Section 5 of the CCAA Homestudy guidelines because in some instances, such as OPERATIONS, fuller reporting is required than is indicated on the Physical Examination form itself. -- Crawford]

___________ [The following is referred to as Form 2. ] ___________

[Form is effective Feb.1, 2001]

 

CERTIFICATE OF GENERAL PHYSICAL EXAMINATION

FOR ADOPTION APPLICANT

 

 

TO EXAMINING PHYSICIAN:

     Your medical report is of paramount importance to the China Center of Adoption Affairs in its examination
of the adoption qualification of the adopters.  You are kindly requested to fill in all the blanks.  Thank you for your cooperation.

 

Applicants' Names: _____________________________________________DOB: _________________

 

Address:____________________________________________________________________________

 

 

MEDICAL HISTORY:

 

Have you ever had Tuberculosis?         No/Yes    

Tumor?                              No/Yes

Heart Disease?                       No/Yes

Liver Disease?                       No/Yes

Sexual Disease?                     No/Yes

Neuropathy?                          No/Yes

Mental Disease?                    No/Yes

Other Communicable Disease?            No/Yes

Alcoholism or Abuse of Substance?        No/Yes

Any Genetic Disease?                  No/Yes

Any Operation?                            No/Yes

 

 

PHYSICAL EXAMINATION:

 

Height:______m    Weight:______kg      Blood Pressure:______________

Vision: L______R______

Hearing: L: Normal/Abnormal; R: Normal/Abnormal

Heart: Normal/Abnormal       Liver: Normal/Abnormal  

Lung: Normal/Abnormal       Lymph: Normal/Abnormal

Thyroid: Normal/Abnormal   Nerve System: Normal/Abnormal

Blood Test (Date of Test):

    Routine Blood Test: Normal/Abnormal   HbsAg: Negative/Positive 

    Liver Function: Normal/Abnormal

Urinalysis (Date of Test):

    Routine Urine Test: Normal/Abnormal

HIV Test (Date of Test):             Negative/Positive

Is the patient taking any medication?           For what purpose?____________________

 

 

PHYSICAL TEST RESULT:

 

     Is there any physical, mental or psychological unfavorable elements of the
adoption applicant, which will affect the upbringing of the child?

 

Is the adoption applicant's state of health suitable for raising a child?

 

 

Physician's Signature:                                                Date:

MD License No. 

 

 

 

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