> SURnMddddtSxSx#l,loa ZNQuestions for the Director/ Caregiver/Doctor
Child s Name: ______________________________________________
The child s birth date: ____________________________________________________________
Where was the child born, e.g. town/hospital name: ___________________________________
Who named the child: ____________________________________________________________
Date the child entered the institution: _______________________________________________
Length of time the child spent with his/her birth family: _________________________________
Length of time the child spent in the baby house: ______________________________________
What is the child s ethnic background? ______________________________________________
Reason why the child is placed for adoption: __________________________________________
______________________________________________________________________________
Does the baby house have the relinquishment paper signed by the parents?_________________
If the parental rights were terminated, does the baby house have the court papers? __________
What is the birth mother s name: ___________________________________________________
How old is the child s mother? _____________________________________________________
How many pregnancies for the mother? _____________________________________________
What is the mother s date of birth or just her age: _____________________________________
What is the mother s physical description (her built, color of eyes, color of hair ) _____________
______________________________________________________________________________
What is the mother s occupation: ___________________________________________________
What was the mother's health during pregnancy: ______________________________________
What is the mother s history of alcohol abuse: ________________________________________
What is the mother s history of drug abuse: __________________________________________
Was the pregnancy full term: ______________________________________________________
Was there any complications with delivery: _________________________________________
What is the birth father s name: ___________________________________________________
What is the birth date of the father or just his age: ____________________________________
What is the father s occupation: ___________________________________________________
What is the father s physical description: ____________________________________________
Where are the birthparents from, which city/town: ____________________________________
Names and ages of other siblings: __________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
What is known about the health history of the parents and siblings if any: __________________
______________________________________________________________________________
______________________________________________________________________________
Was baby premature? ___________________________________________________________
Number of weeks premature if applicable: ___________________________________________
Normal delivery or C-section: ______________________________________________________
What was the child's Apgar scores and at what minute intervals: _________________________
______________________________________________________________________________
Child s birth weight: ______________________________________________________________
Child s birth height: ______________________________________________________________
Child s head circumference at birth: _________________________________________________
Range of measurements over time:
DateAgeHeightWeightHead Circumference
What antibiotics has the child been given: ____________________________________________
______________________________________________________________________________
Was child hospitalized since birth:___________________________________________________
Reason:________________________________________________________________________
______________________________________________________________________________
Any injuries the child may have endured: _____________________________________________
______________________________________________________________________________
Has the child had any illnesses, and if so how were they treated: __________________________
______________________________________________________________________________
Any allergies the child may have:____________________________________________________
______________________________________________________________________________
If child tested positive for syphilis at birth, was he tested again and what was the results: _____
______________________________________________________________________________
If child tested positive at birth for HIV, was he tested again afterwards and what were the results: _______________________________________________________________________
What is the lab results for HIV: _____________________________________________________
What is the lab results for Hepatitis A & B: ____________________________________________
What is the lab results for syphilis: __________________________________________________
What is the lab results for tuberculosis: ______________________________________________
Immunizations the child has received:
Name of vaccinationDate(s) administered
How many children are in the baby house:____________________________________________
How many care takers in the orphanage: _____________________________________________
What is the child s routine: ________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
How does the doctor thinks the child compares to other babies of his/her age at the orphanage:
______________________________________________________________________________
Has the child have any convulsions what the doctor knows of: ____________________________
Does the baby house have pictures of the child when younger, if so, may we take a picture of it:
______________________________________________________________________________
What food do you feed the child and what is the feeding schedule: _______________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Do you have a difficult time feeding him/her? Is she very picky: __________________________
How does the child sleep: (good, difficult, fret a lot): ___________________________________
Can I see the child with his/her caregiver communicate without him/her seeing us: ___________
What is the personality of the child: _________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Is there a caregiver the child is very attached to? If so, what is her name: ___________________
______________________________________________________________________________
Ask the doctor if she can do the following physical assessment of the child in front of you:
Are the muscle mass and fat on arms and legs approximately equal?(indicating the baby is equally coordinated and developed on both sides)Any deformities or birthmarks?
With baby on his/her tummy; are the creases at the back of the legs where the knees bend and at the buttocks the same on both legsWhile on the tummy, does the doctor feels any unusual curvature while running her thumbs up the baby's spineWith baby lying on his/her back, does he/she have painless full range of motion with arms and legsCan baby turn his neck painlesslyCan the baby clenches and unclenches his/her fist
When the doctor shines a flashlight into one eye of the baby, does the pupil constricts and delates? Should be the same for both eyesWhen the doctor holds a light 45 cm(18 inches) away from the baby, slowly moving it across from left to right and back. Does the baby s eyes follow it together without crossing or driftingIf the doctor clap her hands on one side of the child once, does the baby turn his/her eyes and face towards the direction of the clapping? Must be the same for both sides.If the white part of the baby's eyes is not white, ask the doctor if she have any idea why its not?
Is the ear canals properly located inside the ear and are they unobstructed?Is the results within the normal range?
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