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Our Services :: Assessment of Child's Medical History :: Medical Template for Russian Two-Trip Referral and Ukranian One-Trip Referral


Date of referral

Name of child

Date of Birth

Place of Birth

Home Birth or Hospital Birth
Pregnancy history (number of pregnancies, births, health issues during pregnancy)

Apgar scores at one minute and five minutes after birth

Type of delivery
(vaginal or cesarean section)

Health at time of birth

Birth weight, height, head circumference

Date of admission to infant hospital if applicable
Date of admission to orphanage

Family/Social history
Mother (age, profession,etc.)
Father (age, profession,etc.)
Siblings (at home, in orphanages, etc.)
Alcohol, drugs, smoking history for parents

Weight, height, head circumference at 3 months, 6 months, 9 months, one year, etc. as appropriate for age of child--a pattern of growth determines reliability of the measurements; head circumference is key in this collection of data

Physical Exam of Child

Health issues while in the orphanage
(Bronchitis, asthma, anemia, vomiting, diarrhea, allergies, heart murmur, urinary tract infection, skin rashes, chronic medical issues)

Medical interventions

(perinatal encephalopathy, psychomotor delay, hip dysplasia, motor dysfunction, hypotrophy, intracranial hypertension, neuro-reflex hyperexcitability, muscle dystonia, myopathy, myotonia, retinal angiopathy, intestinal dysbacteriosis, cardiopathy, etc.)

Ultrasound evaluations of organ systems (commonly done in Russia)

Blood tests (results and dates of tests)
HIV, Hepatitis B, Hepatitis C, syphilis, complete blood count, etc.

Vaccines (names and dates) -- This is especially important for children over one year of age as we can use some of the vaccines if the dates and intervals are appropriate and the child has adequate antibody titers when evaluated in the U.S.
BCG, DPT, OPV, Hepatitis B, Measles, Mumps, etc.

Developmental commentary
Use Denver pre-screening Developmental Questionaire II (parent inventory)
Milestones by age
Reaching for objects
Sitting independently
Pulling to a stand
Standing alone
Understands simple commands
Vocalizes vowel sounds, consonants, single words, puts two words together, etc.

3 photos to evaluate for fetal alcohol syndrome (portrait, profile, & 3/4)
Video to evaluate development (not always available, but parents often make a video on their own and bring this home for a doctor to review; some families may have the ability to send MPG video via mail)

iph International Pediatric Health Services, PLLC
Dr. Jane Aronson, FAAP
338 East 30th Street, #1R
New York, NY 10016
P: 212.207.6666
F: 212.207.6665
E: E-mail us


Please be prepared to leave a complete phone number and hotel room number when calling from abroad.

  This page last updated March 7, 2010 9:18 PM EST