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Type of Child Acceptable to Family Checklist

ICAB checklist for type of child acceptable to family

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TYPE OF CHILD ACCEPTABLE TO FAMILY
FAMILY NAME:

DATE

Accept
I. CHILD'S STATUS AND HEALTH CONDITION

1. AGE:
Please Indicate Range
0 - 24 months old
25 - 48 months old
49 - 72 months old
73 - 96 months old
8 and above
Others (please idicate)
2. SIBLING STATUS:
Single Child
Sibling Group of Two
Sibling Group of More Than Two (Please specify)
3. BIRTH CONDITION:
Premature
Undescended Testicle
Umbilical Hernia
Physical Abnormalities
Cleft lip
Cleft Palate
4. EYE CONDITION:
Visual acuity abnormalities (sight in one eye, partially blind)
Strabismus (roving eye, surgically correctable)
5. EAR CONDITION:
Hearing impairment
Ear deformity
6. HEART PROBLEMS:
Heart murmur
Heart Defect (May require surgery)
7. HEMATOLOGIC DISORDER:
G6PD
Thalasemia
Others

Not Accept

8. INFECTIOUS DISEASES:
Positive for hepatitis B
First degree infection, under medication
9. ORTHOPEDIC PROBLEMS:
Hand anomalies
Leg anomalies (bowed legged)
Foot anomalies (requiring cane, leg braces, or splint)
Facial feature anomalies
10. EMOTIONAL AND SOCIAL DEVELOPMENT
Autism
ADHD
Known history of physical / sexual abuse
11. DEVELOPMENTAL DELAYS
Cerebral palsy
Seizures
Speech related problems (stuttering, lisps, etc.)
Gross motor delay
Hyperactivity
Slight developmental delay
Global developmental delay
Speech delay
Mental retardation (mild)
II. PARENTAL BACKGROUND:
A. No known information
(if with information proceed to B)
B. History of drug use
History of alcohol
History of emotional illness (e.g. depressionm etc.)
History of mental illness (e.g. schizophrenia, psychosis)
Mentally challenged
With criminal record
Child of rape
Child of incest
OTHER SPECIFIC CONDITION/S YOU MAY CONSIDER RELEVANT:
Lactose intolerance
Skin condition - Eczema
- Dermatitis
Bronchial asthma
Hypo / Hyperthyroidism
Needing surgical procedure / s
Large Hemangioma (which will disappear over time)
Dental carries
Accomplished by:
_______________________
Date:___________
Under the guidance of: ______________________

____________________________
Date:_______________
 
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