Name, date of birth, gender, weight and height.

A family health history of the parents, the brothers and sisters (if any) and the children (if any) of the prospective adopter, with details of any serious physical or mental illness and inherited and congenital disease.

Infertility or reasons for deciding not to have children (if applicable).

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.

Obstetric history (if applicable).

Details of any present illness, including treatment and prognosis.

A full medical examination.

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

Any other relevant information which the agency considers may assist the panel.

The signature, name, address and qualifications of the registered medical practitioner who prepared the report, the date of the report and of the examinations carried out together with the name and address of any other doctor who may be able to provide further information about any of the above matters.