NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES 

DIVISION OF SOCIAL SERVICES 

 

 

(Name of Agency Requesting Information) 

 

In order to protect the agency/facility and the children who may reside in the family foster home 
or residential child care facility, the agency must obtain medical information on the person 
whose name appears below in order to be in compliance with licensure rules. The person named 
below has given the agency permission to obtain their medical report and to the release of 
information by the licensed medical provider, also named below. 

 

I, , agree to the release of pertinent 
information by the licensed medical provider, . Date: 

______________________________________________________________________________ 
Name Age 

Address 

Height Weight Blood Pressure Pulse 

 

History of Illnesses: 

Yes

 

No

 

 

Yes

 

No

Tuberculosis or other 
pulmonary defects 

 

 

 

 

Fainting and dizzy spells 

 

 

 

Venereal disease 

 

 

 

 

Heart Trouble 

 

 

 

Seizures 

 

 

 

 

Serious defects of bones and 
joints 

 

 

 

Mental or emotional 
disturbance 

 

 

 

 

Other chronic or 
communicable diseases 

 

 

 

Hypertension 

 

 

 

 

Specify if yes: 

 



 

 

Physical Examination (Circle all that were examined.) 

 Heart Lungs Abdomen Genitalia 

 ENT Extremities Hernia Eyes 

Date of examination: 

Date of tuberculin skin test: Result: Positive Negative 

Date of chest X-ray*: Findings: 

 *(Required only if tuberculin test positive) 

 

Please comment on any physical, mental or emotional condition or communicable/infectious 
disease apparent from your examination or any knowledge of the above-named person that might 
affect the health, safety or welfare of children residing in the home of facility: 

 

Physician’s, PA’s or NP’s Signature: Date: 

Address: Phone: