Physicians Report For An Infant Under The Age Of One Year {667}

PHYSICIAN'S REPORT FOR AN INFANT UNDER THE AGE OF ONE YEAR 6th Judicial Circuit-Family Division Oakland County Adoption Services 1200 North Telegraph Road Pontiac, MI 48341 RE: DOB: Dear Dr. . I hereby authorize you to release to Oakland County Adoption Services information regarding my current and past physical and mental health. Sincerely, TO BE COMPLETED BY THE PHYSICIAN BIRTH HISTORY INFORMATION Weight Head Circumference Results of PKU Test Height Chest Circumference APGAR Source Complications at Birth: Abnormalities Noted at Birth: CURRENT HEALTH STATUS Weight Head Circumference Head, Neck Eyes Nose Lungs Abdomen Extremities Height Chest Circumference Skin (rash, birth marks) Ears Mouth Heart Genitals Reflexes Formula and Diet: HIV Information (Optional): Immunizations: Medications Prescribed: Remarks on Medical Examination: PLEASE PRINT OR TYPE Physician's Name Address City, State, Zip Code Telephone Number PHYSICIAN'S SIGNATURE DATE OF EXAMINATION Physician's Report for an Infant under the Age of One Year.doc Rev. August, 2006 American LegalNet, Inc. www.FormsWorkflow.com