REPORT OF MEDICAL EXAMINATION - Adult

  • M.D. have examined the above named patient
  • health. Based upon my
  • or mental health concern that would in anyway impair his/her abillty to adopt or to subsequentiy rear and care for the child.

    find (circle one) any evidence of a history of substance abuse.
  • The Following tests were administered(if indicated):

        

    Results/Date

  • The following medication were prescribed:

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17 W. Pall Mall Street
Winchester, Virginia 22601

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Serving the entire State of Virginia – (540) 532-3272