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SCHEDULE 4E+W

Regulation 25(3)(a)

PART 2 E+WREPORT ON THE HEALTH OF THE PROSPECTIVE ADOPTER

1.  Name, date of birth, sex, weight and height.E+W

2.  A family health history of the parents, any brothers and sisters and the children of the prospective adopter, with details of any serious physical or mental illness and hereditary disease or disorder.E+W

3.  Infertility or reasons for deciding not to have children (if applicable).E+W

4.  Past health history, including details of any serious physical or mental illness, disability, accident, hospital admission or attendance at an out-patient department, and in each case any treatment given.E+W

5.  Obstetric history (if applicable).E+W

6.  Details of any present illness, including treatment and prognosis.E+W

7.  Details of any consumption of alcohol that may give cause for concern or whether the prospective adopter smokes or uses habit-forming drugs.E+W

8.  Any other relevant information which the adoption agency considers may assist the adoption panel and the adoption agency.E+W