I R N				I R N
____	HIV Positive	O O O		____	Chronic Constipation	O O O
____	AIDS	O O O		____	Syphilis	O O O
____	HBS positive	O O O		____	Fetal Alcohol Syndrome	O O O
____	Hepatitis A	O O O		____	Vision Disorders	O O O
____	Hepatitis B	O O O		____	Auditory Disorders	O O O
____	Hepatitis C	O O O		____	Skin Disorders	O O O
____	Respiratory Disorders	O O O		____	Neurological Disorders	O O O
____	Tuberculosis	O O O		____	Epilepsy	O O O
____	Asthma	O O O		____	Autism	O O O
____	Pneumonia	O O O		____	Asperger's Disorder	O O O
____	Rickets	O O O		____	Tourette's Syndrome	O O O
____	Kidney Disorders	O O O		____	Cerebral Palsy	O O O
____	Liver Disorders	O O O		____	Fragile X Syndrome	O O O
____	Diabetes	O O O		____	Congenital Physical Defects	O O O
____	Gastro-Intestinal Disorders	O O O		____	Major Dental Problems	O O O
____	Intestinal Parasites	O O O		____	Other: _____________	O O O

Please list any pre-existing condition that was diagnosed only after the initial evaluation:

___________________________________________________________________________________________

 

	Yes	No	If yes, what diagnosis was provided:
Speech Therapy	O	O	_____________________________________
Occupational Therapy	O	O	_____________________________________
Special Education	O	O	_____________________________________
Physical Therapy	O	O	_____________________________________
Attention Deficit Disorders	O	O	_____________________________________
Attachment Disorders	O	O	_____________________________________

For any professionally diagnosed conditions, please indicate:
1. What treatment your child has received or will receive

____________________________________________________________

2. Has the condition been corrected? yes __________ no ___________

3. If "no," has the professional treating your child indicated that the condition is correctable? yes ______ no ______

 

		I R N
_____	An exaggerated fascination with gruesome materials	O O O
_____	An excessive need to be "in control" at all times	O O O
_____	An inability to empathize with how others feel	O O O
_____	Superficial friendliness towards others	O O O
_____	A significant lack of authenticity or sincerity in how he or she relates with others	O O O
_____	Indiscriminate boundaries (For example, he or she approaches strangers with same degrees of closeness or affection as he or she approaches family members)	O O O
_____	Disrespects others' property or takes others' property without permission	O O O
_____	Refuses to tell the truth	O O O
_____	Is abnormally manipulative	O O O
_____	Rejects affection from those he or she should trust to give affection	O O O
_____	Cannot establish eye contact	O O O
_____	Is hyperactive	O O O
_____	Has learning problems and disabilities	O O O
_____	Is cruel to pets	O O O

6. Please indicate if you agree ___ disagree ___ with the following statement:
My adopted child should have been placed in special therapy(s) from the day he or she arrived in the United States. Please explain:

__________________________________________________________________________________

 

	OVERALL	1 2 3 4	A B
1.	My child's overall adjustment since leaving the orphanage has been positive	O O O O	O O
2.	My child has adjustment problems that I think will be resolved	O O O O	O O
3.	My pediatrician believes my child is in good health	O O O O	O O
	FAMILY AND SOCIAL RELATIONSHIPS
4.	My extended family is supportive of our adoption	O O O O	O O
5.	My child is affectionate towards family members	O O O O	O O
6.	My child seeks the attention of family members when scared or sad	O O O O	O O
7.	My child likes to go places with my family	O O O O	O O
8.	My child can communicate his or her wants and needs to family members	O O O O	O O
9.	My child likes to help our family with daily activities	O O O O	O O
10.	My child shows interest in talking with family members	O O O O	O O
11.	My child generally relates well with siblings (if relevant)	O O O O	O O
12.	My child relates well to other children	O O O O	O O
13.	My child shows empathy toward the feelings of peers and/or siblings	O O O O	O O
14.	Other children like my child	O O O O	O O
15.	My child shares fairly well with others	O O O O	O O
16.	Other parents probably think my child is overly aggressive when playing with their children	O O O O	O O
17.	My child is open and responsive to physical affection	O O O O	O O
18.	My child can communicate his or her wants and needs to other caretakers	O O O O	O O
19.	My child can communicate his or her wants and needs to others who are only slightly familiar with my child	O O O O	O O
	BEHAVIOR MANAGEMENT /GENERAL BEHAVIOR
20.	My child sleeps well at night	O O O O	O O
21.	I feel comfortable leaving my child alone with a baby-sitter	O O O O	O O
22.	My child has been cared for by an extended family member who was able to manage my child's needs and behaviors	O O O O	O O
23.	My child can tolerate changes in daily routines	O O O O	O O
24.	My child's behavior has been determined appropriate for day care or school	O O O O	O O
25.	My child can begin and complete an activity in constructive ways	O O O O	O O
26.	My child plays well with other children in a manner that is acceptable for his or her age	O O O O	O O
27.	My child plays well with toys that are age and gender-appropriate	O O O O	O O
28.	My child only enjoys solitary play	O O O O	O O
29.	My child engages in parallel play rather than playing with other children	O O O O	O O
30.	My child enjoys recreational activities	O O O O	O O
31.	My child can feed him or herself	O O O O	O O
32.	My child has a good attention span	O O O O	O O
33.	My child has excessive temper tantrums and/or screams excessively in ways that are unmanageable	O O O O	O O
34.	These temper tantrums involve violent or aggressive behavior	O O O O	O O
35.	My child fusses or fidgets uncontrollably when not involved in a structured activity	O O O O	O O
36.	My child takes too many risks and is often dangerous to him or herself	O O O O	O O
37.	My child bites him or herself or others frequently	O O O O	O O
	EMOTIONAL STATUS
38.	My child has shown pride in him or herself	O O O O	O O
39.	My child is overly quiet and withdrawn	O O O O	O O
40.	My child responds cooperatively when reprimanded	O O O O	O O
41.	My child displays signs of having been abused or threatened with abuse prior to his or her placement in our home	O O O O	O O
	Please explain:
	_______________________________________________
42.	My child is easily distracted	O O O O	O O
	INSTITUTIONAL BEHAVIORS
43.	My child rocks when anxious or tired	O O O O	O O
44.	If the answer to 43 is agree or somewhat agree, please answer: My child's rocking can be calmed when I comfort him or her. Yes ________ No ________
45.	My child often bangs his or her head when stressed, angry or disappointed	O O O O	O O
46.	My child is afraid of moving objects	O O O O	O O
47.	My child has abnormal eating habits that are unmanageable	O O O O	O O
48.	My child shows no reaction to getting hurt	O O O O	O O
	SENSORY-MOTOR DEVELOPMENT
51.	My child has difficulties related to toilet training	O O O O	O O
52.	My child has difficulties eating solids	O O O O	O O
53.	My child has well-developed gross motor skills (is coordinated)	O O O O	O O
54.	My child enjoys a bath or shower	O O O O	O O
55.	My child does not become overly upset when having his or her face washed	O O O O	O O
56.	My child is not overly concerned about getting his or her hands dirty	O O O O	O O
57.	My child tolerates having his or her socks and shoes off	O O O O	O O
58.	My child refuses to go barefoot on any surface	O O O O	O O
59.	My child puts non-food items in his or her mouth	O O O O	O O
60.	My child licks objects rather than using them for what they are intended	O O O O	O O
61.	My child cannot tolerate riding in the car	O O O O	O O
62.	My child can tolerate weather changes	O O O O	O O
63.	My child appears to be overly sensitive to clothing textures, tags, seams, etc.	O O O O	O O
64.	My child has an unusual like of being spun around at very fast speeds	O O O O	O O
65.	My child likes to use crayons, markers or pencils	O O O O	O O
66.	My child's small motor skills are adequate	O O O O	O O

PHYSICAL GROWTH

 

Child's percentile measurements (please graph with an "x")		<10%_____25%_____50%_____75%_____100%
First Exam	Weight	_______________________________________
	Height	_______________________________________
Most recent exam	Weight	_______________________________________
(date____________)	Height	_______________________________________

On a scale of 1 to 5 (5 being extremely stressful) please evaluate the level of stress you have experienced: