ࡱ>   Vbjbj}} HzW <<<<<PPP8,P`"888l* |```````$ub'e@`E< ll @`<<884`r%r%r% F<8<8`r% `r%r%VZ8îd FX4``0`Xe&!ehZe<Z r% @`@`@#2 ` e : Tennessee Department of Children s Services Foster Parent/Other Adult Medical Report  FORMCHECKBOX  Foster Parent  FORMCHECKBOX  Other Household Adult  FORMTEXT       FORMTEXT      Last NameFirst Name SMOKING Do you smoke?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Number/packs of cigarettes per day  FORMTEXT      MEDICAL Are you currently seeing a specialist?  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If the person is identified as other adult living in the home, indicate conditions detrimental to a child s placement in the home.  FORMTEXT       FORMTEXT       FORMTEXT       On the basis of this examination and my knowledge of this patient,  FORMCHECKBOX I recommend  FORMCHECKBOX  do not recommend this person as a foster or adoptive parent for children.  FORMCHECKBOX  This is not a foster parent applicant. On the basis of this examination and my knowledge of this patient, I have no concerns with this person residing with children. Comments FORMTEXT       FORMTEXT       FORMTEXT       Physician Name/NP/PA Name Patient s primary care physician FORMCHECKBOX  Yes  FORMCHECKBOX  No Physician/NP/PA Signature Date     Check the  Forms Webpage for the current version and disregard previous versions. This form may not be altered without prior approval. 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