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:

OFFICE ADDRESS:

124 Amherst St Winchester, Virginia 22601

PHONE NUMBERS:

Winchester – (540) 532-3272

Fairfax - (703) 200-9099

Charlottesville – (434) 825-1162