List of special needs – Bulgaria / Lista over särskilda behov - Bulgarien Please, fill in this form, marking YES, NO or MAYBE each of possible special needs listed further down. This form doesn’t oblige you to adopt a given child, but gives you directions to follow when discus with your family adoption of a child with special needs. Var snäll och fyll i genom att markera YES (ja), NO (nej) eller MAYBE (kanske) för vart och ett av de särskilda behoven som är listade nedan. Detta formulär förpliktigar inte att adoptera ett givet barn, men ger riktlinjer att följa när ni med er familj diskuterar adoption av ett barn med särskilda behov. SEX (KÖN) MALE OR FEMALE DOES NOT MATTER / Manlig eller kvinnlig ej av betydelse AGE / ÅLDER YES MAYBE YES MAYBE YES MAYBE YES MAYBE YES MAYBE YES MAYBE YES MAYBE YES MAYBE ………………… NO NO NO NO NO NO NO NO NO DATA / Inga uppgifter YES MAYBE NO HISTORY OF: / Bakgrund med DRUGS USE / Bruk av narkotika ALCOHOL USE / Bruk av alkohol) PSYCHIATRIC DISEASES /Psykisk sjukdom SCHIZOPHRENIA / Schizofreni CRIME RECORDS / Kriminalitet MENTAL RETARDATION / Mental efterblivenhet PHYSICAL HANDICAP / Fysiskt handikapp CHILD BORN OF INCEST / Barn tillblivet genom incest CHILD BORN OF RAPE / Barn tillblivet genom våldtäkt MOTHER WITH SYPHILIS / Moder med syfilis HIV POSITIVE MOTHER / HIV-positiv moder YES YES YES YES YES YES YES YES YES YES YES MAYBE MAYBE MAYBE MAYBE MAYBE MAYBE MAYBE MAYBE MAYBE MAYBE MAYBE NO NO NO NO NO NO NO NO NO NO NO 0-2 YEARS/ 0-2 ÅR 2-3 YEARS/ 2-3 ÅR 3-4 YEARS / 3-4 ÅR 4-5 YEARS / 4-5 ÅR 5-6 YEARS / 5-6 ÅR 6-7 YEARS / 6-7 ÅR 7-8 YEARS / 7-8 ÅR 8 AND ABOVE / 8 ÅR OCH ÖVER OTHER, PLEASE POINT / ANNAN, ANGE FAMILY HISTORY / FAMILJEBAKGRUND CHILD PHYSICAL CONDITION, CHILD’S CONDITION ON DELIVERY / BARNETS FYSISKA KONDITION, BARNETS KONDITION VID FÖDSELN BORN BEFORE 36 GESTATION WEEK / Fött före 36:e gestationsveckan BIRTH WEIGHT UNDER 2 KG/Födelsevikt under 2 kg ICTERUS (JAUNDICE) / Ikterus (Gulsot) Sign. …………………………………………….. YES MAYBE YES MAYBE YES MAYBE NO NO NO Sign. …………………………………………….. RESPIRATORY DISTRESS SYNDROME/ Andningssviktssyndrom MULTIPLE CONGENITAL ANOMALIES / Multipel medfödd missbildning UMBILICAL HERNIA / Navelbråck IMPERFORATE ANUS / Analatresi YES MAYBE NO YES MAYBE NO YES MAYBE NO YES MAYBE NO SKIN CONDITION / Hud SCARS ON BODY FROM DELIVERY, REQUIRING SURGICAL REMOVAL/ Ärr/födelsemärke från födseln som kräver kirurgiskt ingrepp YES MAYBE SMALL SCARS ON BODY FROM DELIVERY (Not surgical) /Små ärr/födelsemärken från födseln (Icke kirurgiskt) YES MAYBE LARGE SCARS ON BODY FROM DELIVERY/Stora ärr på kroppen från födseln (Not surgical) / (Icke kirurgiskt) YES MAYBE SCARS ON FACE FROM DELIVERY / Ärr i ansiktet från födseln (Not surgical) / (Icke kirurgiskt) YES MAYBE MONGOLIAN SPOT (disappear with growing) / Mongolfläck (försvinner med åldern) YES MAYBE RAISED ANGIOMA / Upphöjt angiom YES MAYBE RED CONGENITAL ANGIOMA / Rött medfött angiom YES MAYBE SMALL NEVUSES / Små nevus YES MAYBE LARGE NEVUSES / Stora nevus YES MAYBE SMALL BURN SCARS / Små brännskador YES MAYBE LARGE BURN SCARS / Stora brännskador YES MAYBE PSORIASIS / Psoriasis YES MAYBE VISION / Syn ONE EYE BLIND / Ingen syn på ett öga ONE EYE MISSING / Saknar ett öga PARTIAL BLINDNESS (one operation could help) / Partiell blindhet ( en operation skulle kunna hjälpa) TOTAL BLINDNESS / Blindhet STRABISMUS / Strabism (skelögdhet) NYSTAGMUS / Nystagmus POSSIBLE VISION PROBLEMS, CORRECTABLE WITH GLASSES / Möjlig synnedsättning, korrigerbart med glasögon POSSIBLE VISION PROBLEMS, CORRECTABLE WITH SURGERY Möjlig synnedsättning, korrigerbart med kirurgi GLAUCOMA / Glaukom COLOBOMA / Kolobom MOUTH CONDITION / Mun CLEFT PALATE / Gomspalt CLEFT LIP ONE SIDE / Ensidig läppspalt CLEFT LIP BILATERALLY / Dubbelsidig läppspalt CLEFT LIP AND PALATE / Läpp- och gomspalt FACE DEFORMITY /Ansiktsdeformation Sign. …………………………………………….. YES MAYBE YES MAYBE NO NO NO NO NO NO NO NO NO NO NO NO NO NO YES MAYBE NO YES MAYBE NO YES MAYBE NO YES MAYBE NO YES MAYBE NO YES MAYBE YES MAYBE YES MAYBE NO NO NO YES YES YES YES YES NO NO NO NO NO MAYBE MAYBE MAYBE MAYBE MAYBE Sign. …………………………………………….. HEARING CONDITION / Hörsel EAR INFECTIONS (OTITIS AND ETC.) / Öroninfektioner (Otitis o. dyl.) PARTIAL DEAFNESS / Partiell dövhet DEAF AND DUMB/ Dövstum DEAFNESS WITHOUT DUMBNESS / Döv men ej stum EAR DEFORMITY (hearing not lost) / Örondeformation (bibehållen hörsel) EAR DEFORMITY (hearing lost) /Örondeformation (förlorad hörsel) EAR ATRESIA, WITHOUT HEARING LOST/ Atresi (bibehållen hörsel) YES YES YES YES MAYBE NO MAYBE NO MAYBE NO MAYBE NO YES MAYBE YES MAYBE NO NO YES MAYBE NO YES MAYBE YES MAYBE YES MAYBE NO NO NO YES MAYBE NO YES YES YES YES YES YES YES YES YES YES MAYBE MAYBE MAYBE MAYBE MAYBE MAYBE MAYBE MAYBE MAYBE MAYBE NO NO NO NO NO NO NO NO NO NO HEART MURMUR /Blåsljud på hjärtat YES HEART DISEASES AND ANOMALIES/ Hjärtsjukdomar och anomalier YES POSSIBLE OPEN HEART OPERATION (operation with opening of the chest) / Eventuell hjärtoperation (operation genom att öppna bröstet) YES ATRIAL SEPTUM DEFECT / Förmaksseptumdefekt YES VENTRICULAR SEPTUM DEFECT / Ventrikulär septumdefekt YES MAYBE MAYBE NO NO MAYBE MAYBE MAYBE NO NO NO MAYBE MAYBE MAYBE MAYBE NO NO NO NO GROWTH RETARDATION / tillväxtförsening PSYCHOLOGICAL AND PHYSICAL RETARDATION / Psykisk och fysisk försening GRAVE MOTOR RETARDATION / Grav motorisk försening EPILEPTIC SEIZURES / Epileptiska anfall EARLIER HISTORY OF SEIZURES / Tidigare sjukdomshistoria med kramper SLIGHT PSYCHOMOTORIC RETARDATION / Lätt psykomotorisk försening TOTAL RETARDATION / Total försening MENTAL RETARDATION (moderate)/Mental försening (moderat) MENTAL RETARDATION (grave) / Mental försening (grav) SLIGHT SPEECH RETARDATION / Lätt försenat tal SPEECH DIFFICULTIES / Talsvårigheter DYSLEXIA / Dyslexi DIFFICULTIES IN LEARNING /Inlärningssvårigheter FETAL ALCOHOL SYNDROME / Fetalt alkoholsyndrom FETAL ALCOHOL EFFECT / Fetala alkoholeffekter HEART PROBLEMS HERNIA / Hjärtproblem / Bråck CRYPTORCHISM / Kryptorkism (testiklar kvar i bukhålan) HERNIA / Bråck HYPOSPADIAS / Hypospadi PHIMOSIS / Förhudsförträngning Sign. …………………………………………….. YES YES YES YES Sign. …………………………………………….. INFECTIOUS DISEASES / Infektionssjukdomar PARASITES / Parasiter TBC POSITIVE / TBC-positiv VDRL POSITIVE (treated after delivery) / Syfilistest VDRL-positiv (behandlad efter födseln) HEPATITIS B POSITIVE / Hepatit B positiv HEPATITIS C POSITIVE Hepatit C positiv HIV POSITIVE / HIV-positiv CHILD HIV-NEGATIVE BUT WITH HIV ANTIBODIES AT BIRTH / Barn HIV-negativt men med antikroppar mot hiv vid födseln YES MAYBE YES MAYBE NO NO YES YES YES YES MAYBE MAYBE MAYBE MAYBE NO NO NO NO YES MAYBE NO ORTHOPEDIC PROBLEMS / Ortopediska problem SHORT HEIGHT (ACHONDROPLASIA)/Dvärgväxt (Akondroplasi) YES ONE ARM SHORTER/ Ena armen kortare YES ONE LEG SHORTER /Ena benet kortare YES RACHITIS / Rakitis YES EQUINOVARUS DEFORMITY / Equinovarus YES AMPUTATED HAND UP TO WRIST / Amputerad hand till handleden YES AMPUTATED ARM UP TO SHOULDER /Amputerad arm till skuldran YES AMPUTATED LEG/ Amputerat ben YES AMPUTATED FOOT / Amputerad fot YES HAND DEFORMITY UP TO WRIST / Deformerad hand till handleden YES ARM DEFORMITY OF UP TO SHOULDER / Deformerad arm till skuldran YES FOOT DEFORMITY / Deformerad fot YES LEG DEFORMITY / Deformerat ben YES MISSING FINGERS /Avsaknad av något eller flera fingrar YES MISSING TOES/Avsaknad av någon eller flera tår YES DEFORMATION OF FINGERS / Deformerade fingrar YES DEFORMATION OF TOES / Deformerade tår YES WEBBED FINGERS / Sammanväxta fingrar YES WEBBED TOES /Sammanväxta tår YES CONGENITAL HIP ANOMALY / Medfödd höftanomali YES UNDEVELOPED WRIST / Outvecklad handled YES WALKING DIFFICULTIES (needs assistance, crutches, slight hobble) / Svårighet att gå (behöver assistans, kryckor, lätt hälta) YES PARALYSIS – PARAPLEGIA / Förlamning - paraplegi YES ARTHROGRIPOSIS (persistent flexure/ joint contraction) Artrogrypos (stelhet/kontraktur) YES OSTEOGENESIS IMPERFECTA (bone fragility) Osteogenesis imperfecta (benskörhet) YES MULTIPLE ORTHOPEDIC PROBLEMS / Multipla ortopediska problem YES NECESSARY ORTHOPEDIC SURGERY / (broken bones in the past) Nödvändig ortopedisk kirurgi (tidigare brutna ben) YES NEED FOR WHEEL-CHAIR / Behov av rullstol YES NEED FOR CORSET / Behov av stödkorsett YES Sign. …………………………………………….. MAYBE MAYBE MAYBE MAYBE MAYBE MAYBE MAYBE MAYBE MAYBE MAYBE NO NO NO NO NO NO NO NO NO NO MAYBE MAYBE MAYBE MAYBE MAYBE MAYBE MAYBE MAYBE MAYBE MAYBE MAYBE NO NO NO NO NO NO NO NO NO NO NO MAYBE MAYBE NO NO MAYBE NO MAYBE NO MAYBE NO MAYBE MAYBE MAYBE NO NO NO Sign. …………………………………………….. OTHER CORRECTABLE PROBLEMS /Andra korrigerbara problem YES MAYBE NO YES MAYBE NO YES MAYBE NO YES MAYBE NO YES MAYBE NO YES MAYBE NO YES MAYBE NO ASTHMA / Astma ALLERGIES / Allergier BRONCHITIS / Bronkitis PNEUMONIA / Lunginflammation DIGESTION PROBLEMS / Matsmältningsproblem POOR NOURISHMENT / Undernäring LACTOSE INTOLERANCE / Laktosintolerans EMOTIONAL AND SOCIAL GROWTH AUTISM (mild) / Autism (mild) AUTISM (moderate) / Autism (lindrig) AUTISM (grave) / Autism (grav) HYPERACTIVITY / Hyperaktivitet DATA FOR PHYSICAL ABUSE / Uppgift om fysisk misshandel DATA FOR SEXUAL ABUSE / Uppgift om sexuellt utnyttjande NEUROLOGICAL INJURIES / Neurologiska skador BEHAVIOR PROBLEMS / Beteendeproblem CONTROLLED SEIZURES / Kontrollerade anfall TRANSIENT SEIZURES WITH UNKNOWN CAUSE / Övergående anfall av okänd anledning CONTROLLED EPISODES – SERIOUS / Kontrollerade episoder–allvarligt YES YES YES YES YES YES YES YES YES MAYBE MAYBE MAYBE MAYBE MAYBE MAYBE MAYBE MAYBE MAYBE NO NO NO NO NO NO NO NO NO YES MAYBE NO YES MAYBE NO YES YES YES YES YES YES YES MAYBE MAYBE MAYBE MAYBE MAYBE MAYBE MAYBE NO NO NO NO NO NO NO YES MAYBE YES MAYBE YES MAYBE NO NO NO INTERNAL / Inre STATUS AFTER SURGICAL REMOVAL OF ADNEXA / Status efter kirurgiskt borttagande av adnexa RETENTION OF TESTES / Retentio testis DUAL GENITALIA / Dubbla könsorgan HERMAPHRODISM / Hermafrodism HYPOSPADIA / Hypospadi VAGINAL ATRESIA /Vaginal atresi OTHER GENITAL MALFORMATION / Annan genital missbildning DISEASE OF GASTRO-INTESTINAL TRACT / Sjukdom i magtarmkanalen MISSING KIDNEY / Avsaknad av en njure KIDNEY ANOMALY / Njuranomali CENTRAL NERVOUS SYSTEM, CRANIUM, GENETIC/Centrala nervsystemet, kranium, genetiskt HYDROCEPHALY/ Hydrocefali MICROCEPHALY / Mikrocefali SPINA BIFIDA / Spina bifida MYELOMENINGOCELE / Ryggmärgsbråck ALBINISM / Albinism CROOKED OR CURVED VERTEBRAL COLUMN / Böjd eller kutande ryggrad SLIGHT CEREBRAL PARALYSIS / Lätt cerebral paralys (CP) Sign. …………………………………………….. YES YES YES YES YES MAYBE MAYBE MAYBE MAYBE MAYBE NO NO NO NO NO YES MAYBE YES MAYBE NO NO Sign. …………………………………………….. MODERATE CEREBRAL PARALYSIS / Moderat cerebral paralys GRAVE CEREBRAL PARALYSIS / Grav cerebral paralys NEUROFIBROMATOSIS / Neurofibromatos YES MAYBE YES MAYBE YES MAYBE NO NO NO YES YES YES YES NO NO NO NO OTHER / Annat DOWN SYNDROME / Downs syndrom TALASEMIA / Talasemi ANEMIA / Anemi OTHER BLOOD DISEASES /Andra blodsjukdomar MAYBE MAYBE MAYBE MAYBE COMMENTS OR OTHER SPECIAL NEEDS YOU ARE CONCERNED / Kommentarer eller andra särskilda behov ni kan tänka er ………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… Date/datum………………………….. Signature/Underskrift………………………………………….. Name in block letters/Namnförtydligande………………………………………….. Signature/Underskrift………………………………………….. Name in block letters/Namnförtydligande………………………………………….. Sign. …………………………………………….. 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