TO EXAMINING PHYSICIAN:
In evaluating the applicant, this agency and the China Center of Adoption Affairs must be guided by your medical findings as reported on this form. Thank you for your assistance. Please print or type all information. Note "N/A" of "none" if applicable. Please do not leave blank.

Applicant's Name: ____________________________ DOB: ________________
Address: _____________________________________________________________

Medical History:

Have you ever had...             No     Yes     Time    Result
Tuberculosis?                   ____    ____     ____     ______
Tumor?                          ____    ____     ____     ______
Heart disease?                  ____    ____     ____     ______
Liver disease?                  ____    ____     ____     ______
Sexual disease?                 ____    ____     ____     ______
Neuropathy?                     ____    ____     ____     ______
Mental disease?                 ____    ____     ____     ______
Other communicable disease?     ____    ____     ____     ______
Alcoholism or substance abuse?  ____    ____     ____     ______
Any genetic disease?            ____    ____     ____     ______
Any operations?                 ____    ____     ____     ______

PHYSICAL EXAMINATION:

Date of exam:_________Height:_______Weight:______Blood pressure:__________
Vision: ____________________ Hearing: _____________________
Heart: ________________ Liver: ________________ Lung: ___________________
Lymph: ____________________ Thyroid: _____________________
Nervous system: __________________ Uroscope: _____________________
Blood test: ________________________ HIV: _______________________

What is your assessment on the patient's fertility/infertility? _____________________
Is the patient taking any medication? _______________________________________________

PHYSICIAN'S STATEMENT:

Signed: _______________________ MD License No.: ___________ Date: _________
Physician's name (Print clearly): _________________________________________
Address: ___________________________________________________________