Names of adoptive parents:
Address:
Name of the child:
Date of birth/age:
Date of legal adoption/guardianship:
Petition number:

1. General health of the child:
   
2. Details of immunizations:
   
3. Feeding and sleep patterns:
   
4. Motor development:
   
5. Speech and language development:
   
6. Adjustment to family - adoptive parents, siblings, other adults, peers:
   
7. General appraisal of the adoptive situation:

Name:
Signature:
Designation:
Date: