Review of Medical History/Previous Records

• Birth records should be obtained whenever possible, particularly for children younger than 6 y
 ○ Prenatal blood and urine test results of biological mother
 ○ Exposure to medications, illegal substances, alcohol, tobacco
 ○ Gestational age, birth weight, length, head size; Apgar scores
 ○ Prenatal concerns, neonatal complications
 ○ Newborn hearing screening results
 ○ Results of newborn metabolic screening
• Previous growth points, including head circumference
• History of abuse, physical and sexual; history of neglect
• Reason for placement into adoptive home
 ○ Voluntary versus involuntary termination of parental rights
• Nutritional history, particularly with respect to iron, calcium, vitamin D, iodine, and other nutrients
 ○ Assess current dietary habits
 ○ Determine whether the child has any issues eating textured foods
 ○ Exercise history
• Developmental milestones, past and present
• Behavioral issues, particularly with respect to socialization, indiscriminate friendliness
• Laboratory test results, radiographic studies, other studies
• Immunizations
 ○ School records may be sufficient, particularly for older children
 ○ Original records and adequate timing of doses should be verified with antibody titers
 ○ Children with no records or records that do not appear to be original or accurate should be reimmunized
• Results (if known) of previous testing for tuberculosis, including treatment
• Chronic medical diagnoses
• Allergies (medication, food, environmental, latex, insect stings)
• Medications (both used acutely and chronically)
• Reports from previous specialists seen
 ○ Consider having an original translation of records from other countries
• Family history (when available)
 ○ Vision, hearing deficits
 ○ Genetic diseases
 ○ Concerns related to ethnicity (eg, sickle cell anemia, thalassemia, Tay Sachs disease, lactose intolerance)
 ○ Mental health diagnoses
• Environmental risk factors
 ○ Lead risks
 ○ Institutionalization
      • Reason and timing, if known, of placement
      • If known, feeding and sleeping schedule and environment where feeding and sleeping occurred
 ○ Risks for previous physical, emotional, and sexual abuse
      • Substandard housing, multiple changes in residence
      • Family members using illegal substances or alcohol, domestic violence
 ○ Passive tobacco exposure, methamphetamines, other illicit substances in the home environment
 ○ Other environmental toxins, both in the home and in the surrounding community
• Number of prior placements, quality of such care
  • Notes:

  • • Children who have been adopted internationally may have neurologic, hematologic, cardiac, and metabolic disorders that were previously overdiagnosed, underdiagnosed, or missed completely.

  • • Medical records from other countries (if available) may be limited in information, inaccurate, or even falsified.

  • • For children adopted domestically, there may be issues of confidentiality associated with obtaining records, particularly if the child’s name was changed at the time of the adoption. In all cases, physicians should work with families and adoption workers to obtain complete medical records, while also strictly adhering to laws regarding confidentiality of medical information.