1. No category

Version September 2015
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
PHYSICAL HANDICAP
/ Fysiskt handikapp
MENTAL RETARDATION / Mental efterblivenhet
CHILD BORN OF INCEST / Barn tillblivet genom incest
CHILD BORN OF RAPE / Barn tillblivet genom våldtäkt
MOTHER WITH SYPHILIS / Moder med syphilis
HIV POSITIVE MOTHER / HIV-POSITIV MODER
 YES
 YES
 YES
 YES
 YES
 YES
 YES
 YES
 YES
 YES
 YES
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
 MAYBE  NO
 MAYBE  NO
 MAYBE  NO
 MAYBE  NO
 MAYBE  NO
 MAYBE  NO
 MAYBE  NO
 MAYBE  NO
 MAYBE  NO
 MAYBE  NO
 MAYBE  NO
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 (YESUNDICE) / Ikterus (Gulsot)
RESPIRATORY DISTRESS SYNDROME/ Andningssviktssyndrom
Sign.:…………………...................
 YES
 YES
 YES
 YES
 MAYBE
 MAYBE
 MAYBE
 MAYBE
Sign.:…………………...................
 NO
 NO
 NO
 NO
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Version September 2015
MULTIPLE CONGENITAL ANOMALIES /
Multipel medfödd missbildning
UMBILICAL HERNIA / Navelbråck
IMPERFORATE ANUS / Analatresi
LACTOSE INTOLERANCE / Laktosintolerans
 YES
 YES
 YES
 YES
 MAYBE  NO
 MAYBE  NO
 MAYBE  NO
 MAYBE  NO
SKIN CONDITION / Hud
SCARS ON BODY FROM DELIVERY, REQUIRING SURGICAL REMOVAL/
Ärr/födelsemärke från födseln som kräver kirurgiskt ingrepp
 YES  MAYBE
 NO
SMALL SCARS ON BODY FROM DELIVERY/Små ärr/födelsemärken
från födseln (Not surgical) / (Icke kirurgiskt)
 YES  MAYBE
 NO
LARGE SCARS ON BODY FROM DELIVERY/Stora ärr på kroppen från födseln
(Not surgical) / (Icke kirurgiskt)
 YES  MAYBE
 NO
SCARS ON FACE FROM DELIVERY / Ärr i ansiktet från födseln
(Not surgical) / (Icke kirurgiskt)
MONGOLIAN SPOT (disappear with growing) /
Mongolfläck (försvinner med åldern)
RAISED ANGIOMA / Upphöjt angiom
RED CONGENITAL ANGIOMA / Rött medfött angiom
SMALL NEVUSES / Små nevus
LARGE NEVUSES / Stora nevus
SMALL BURN SCARS / Små brännskador
LARGE BURN SCARS / Stora brännskador
PSORIASIS / Psoriasis
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
 NO
 MAYBE
 MAYBE
 MAYBE
 MAYBE
 MAYBE
 MAYBE
 MAYBE
 MAYBE
 NO
 NO
 NO
 NO
 NO
 NO
 NO
 NO
 YES  MAYBE
 YES  MAYBE
 NO
 NO
 YES
 YES
 YES
 YES
 MAYBE
 MAYBE
 MAYBE
 MAYBE
 NO
 NO
 NO
 NO
 YES  MAYBE
 NO
 YES  MAYBE
 YES  MAYBE
 YES  MAYBE
 NO
 NO
 NO
 YES
 YES
 YES
 YES
 YES
 NO
 NO
 NO
 NO
 NO
 YES
 YES
 YES
 YES
 YES
 YES
 YES
 YES
 MAYBE
 MAYBE
 MAYBE
 MAYBE
 MAYBE
Sign.:…………………...................
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Version September 2015
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
GROWTH RETARDATION / tillväxtförsening
PSYCHOLOGICAL AND PHYSICAL
RETARDATION / Psykisk och fysisk försening
 YES
GRAVE MOTOR RETARDATION / Grav motorisk försening
 YES
EPILEPTIC SEIZURES / Epileptiska anfall
 YES
EARLIER HISTORY OF SEIZURES / Tidigare sjukdomshistoria med kramper
 YES
SLIGHT PSYCHOMOTORIC RETARDATION / Lätt psykomotorisk försening
 YES
TOTAL RETARDATION / Total försening
 YES
MENTAL RETARDATION (moderate)/Mental försening (moderat)
 YES
MENTAL RETARDATION (grave) / Mental försening (grav)
 YES
SLIGHT SPEECH RETARDATION / Lätt försenat tal
 YES
SPEECH DIFFICULTIES / Talsvårigheter
 YES
DYSLEXIA / Dyslexi
 YES
DIFFICULTIES IN LEARNING /Inlärningssvårigheter
 YES
FETAL ALCOHOL SYNDROME / Fetalt alkoholsyndrom
 YES
FETAL ALCOHOL EFFECT / Fetala alkoholeffekter
 YES
HEART PROBLEMS
 NO
 NO
 NO
 MAYBE
 NO
 MAYBE
 MAYBE
 MAYBE
 MAYBE
 MAYBE
 MAYBE
 MAYBE
 MAYBE
 MAYBE
 MAYBE
 NO
 NO
 NO
 NO
 NO
 NO
 NO
 NO
 NO
 NO
 MAYBE
 MAYBE
 NO
 NO
/ Hjärtproblem
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
HERNIA
 MAYBE
 MAYBE
 MAYBE
 MAYBE  NO
 MAYBE  NO
 MAYBE  NO
/ Bråck
CRYPTORCHISM / Kryptorkism (testiklar kvar i bukhålan)
HERNIA / Bråck
HOPOSPADIAS / Hypospadi
PHIMOSIS / Förhudsförträngning
Sign.:…………………...................
 YES
 YES
 YES
 YES
 MAYBE
 MAYBE
 MAYBE
 MAYBE
Sign.:…………………...................
 NO
 NO
 NO
 NO
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Version September 2015
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 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
 MAYBE
 NO
 NO
 MAYBE
 MAYBE
 MAYBE
 NO
 NO
 NO
Sign.:…………………...................
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Version September 2015
OTHER CORRECTABLE PROBLEMS /Andra korrigerbara problem
ASTHMA / Astma
ALLERGIES / Allergier
BRONCHITIS / Bronkitis
PNEUMONIA / Lunginflammation
DIGESTION PROBLEMS / Matsmältningsproblem
POOR NOURISHMENT / Undernäring
LACTOSE INTOLERANT / Laktosintolerant
 YES
 YES
 YES
 YES
 YES
 YES
 YES
 MAYBE
 MAYBE
 MAYBE
 MAYBE
 MAYBE
 MAYBE
 MAYBE
 NO
 NO
 NO
 NO
 NO
 NO
 NO
 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
EMOTIONAL AND SOCIAL GROWTH
AUTISM (mild) / Autism (mild)
AUTISM (moderate) / Autism (lindrig)
AUTISM (grave) / Autism (grav)
HYPERACTIVITY / Hyperaktivitet
DATA FOR PHYSICAL ABUSE / Uppgift om fysiskt utnyttjande
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
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
VAGINAL ATRESIA /Vaginal atresi
CRYPTORCHISM / Kryptorkism
OTHER GENITAL MALFORMATION / Annan genital missbildning
DISEASE OF GASTRO-INTESTINAL TRACT /
Sjukdom i magtarmkanalen
MISSING KIDNEY / Avsaknad av 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
Sign.:…………………...................
 YES
 YES
 YES
 YES
 YES
 MAYBE
 MAYBE
 MAYBE
 MAYBE
 MAYBE
 NO
 NO
 NO
 NO
 NO
 YES  MAYBE
 NO
Sign.:…………………...................
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Version September 2015
SLIGHT CEREBRAL PARALYSIS / Lätt cerebral paralys (CP)
MODERATE CEREBRAL PARALYSIS / Moderat cerebral paralys
GRAVE CEREBRAL PARALYSIS / Grav cerebral paralys
NEUROFIBROMATOSIS / Neurofibromatos
OTHER
 YES
 YES
 YES
 YES
 MAYBE
 MAYBE
 MAYBE
 MAYBE
 NO
 NO
 NO
 NO
 YES
 YES
 YES
 YES
 MAYBE
 MAYBE
 MAYBE
 MAYBE
 NO
 NO
 NO
 NO
/ Annat
DOWN SYNDROME / Downs syndrom
THALASSEMIA / Talassemi
ANEMIA / Anemi
OTHER BLOOD DISEASES /Andra blodsjukdomar
COMMENTS OR OTHER SPECIAL NEEDS YOU ARE CONCERNED / Kommentarer eller andra
särskilda behov ni kan tänka er
…………………………………………………………………………………………………………………
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Date/datum…………………………..
Signature/Underskrift…………………………………………..
Name in block letters/Namnförtydligande…………………………………………..
Signature/Underskrift…………………………………………..
Name in block letters/Namnförtydligande…………………………………………..
Sign.:…………………...................
Sign.:…………………...................
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