North Carolina agencies that license foster homes send applicants and household members to a clinician with this one-page evaluation. It records vital signs, chronic conditions, a tuberculosis risk screen, communicable diseases, activity limits and behavioral health diagnoses, then asks whether the person is medically cleared to foster or to live in a home with foster children.
A physician, physician assistant or nurse practitioner completes and signs the whole form, circling the applicable title. The requesting agency writes its name at the top; the individual is told the information will go to the NC Division of Social Services.
Download the current version from the source each time; forms change without notice.
Medical Evaluation
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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A physician, physician assistant or nurse practitioner. The signature block asks for the clinician's printed name with the applicable title circled, plus address, phone number and date, after the statement that the clinician examined the person and reviewed their medical history.
Not for everyone. The form lists five risk questions (birthplace or residence in listed regions, immunocompromise, high-risk behavior or setting, exposure to infectious TB, current symptoms). If the assessment shows a TB skin test or chest x-ray is needed, the date and result go on the form.
The clinician answers yes or no to an opinion that the person is medically cleared to serve as a foster parent or to reside as a household member in a home where foster children are present. Chronic conditions, communicable diseases, activity limits and behavioral health diagnoses are explained above it.