HEALTH APPRAISAL

Dear Parent or Guardian: The following information is requested so that the school can work with the parent to meet the physical, intellectual and emotional needs of the child. Fill out the information requested in Section I. Section III may be certified by the transcription of information from the certificate of immunization. The remaining sections are to be completed by a doctor, nurse and dentist. (BE SURE TO BRING YOUR CHILD'S IMMUNIZATION RECORDS TO THE EXAMINATION.)

PERSONAL

CHILD'S NAME
Last Name: First Name: Middle Name: Date of Birth:    
   
 
ADDRESS (Number & Street) City State Zip Code   Today's Date
 
 
PARENT/GARDIAN
Last Name: First Name: Middle Name: Home Telephone Number:  
   
 
ADDRESS (Number & Street) City State Zip Code   Today's Date
 
 

SECTION I - HEALTH HISTORY

Yes No Resolved # Is your child having any of the problems listed below? BIRTH HISTORY
1. Allergies or Reactions (for example, food, medication or other)
2. Hayfever, Asthma or Wheezing
3. Eczema or Frequent Skin Rashes
4. Convulsions/Seizures
5. Heart Trouble
6. Diabetes
7. Frequent Colds, Sore Throats, Earaches (4 or more per year) Are there any current or past diagnosis(es)
8. Trouble with Passing Urine or Bowel Movements If yes, please describe:
9. Shortness of Breath
10. Speech Problems
11. Menstrual Problems
12. Dental Problems: Date of Last Exam
Other (please describe):
 
  Does your child take any medication(s) regularly? If yes, list medications:
Reasons for Medication
Check here to indicate that you have read and agree to the terms.    Date: Was the health history reviewed by a health professional?
 
    Examiner's Initials:
SECTION II - PHYSICAL EXAMINATION, INSPECTION, TESTS AND MEASUREMENTS
Required for Child Care and Head Start/Early Head Start

Tests and Measurements
No Yes
Was child tested for:
Test results: Normal Referred Under Care
VISION
Date:
Visual Acuity
Muscle Imbalance
Other:
HEARING
Date:
Audiometer
Other:
       
URINALYSIS
Date:
Sugar
Albumin
Microscopic
BLOOD LEAD LEVEL
Date:
Level ug/dl
HEIGHT & WEIGHT
  ft. inches lbs.
  Other:
Height:
Weight:
Other:
HEMOGLOBIN/ HEMATOCRIT  
BLOOD PRESSURE
Reading:
TUBERCULIN
 
Date:
Type:
 
Neg:   Pos:   mm
Note: Blood lead level required for all children enrolled in Medicaid must be tested at one and two years of age, or once between three and six years of age if not previously tested. All children under age six living in high-risk areas should be tested at the same intervals as listed above.

Examinations and/or Inspections

Essential Findings Deviating from Normal:
  Exam Date:

MDHHS/BCAL-3305 (formerly OCAL 3305/BRS-3305)

SECTION III - IMMUNIZATIONS
Statements such as "UP-TO-DATE" or "COMPLETE" will not be accepted. Admission to school may be denied on the basis of this information. *
 
VACCINES (Select Type) DATE ADMINISTERED
Hepatitis B
(Hep B)
1 3
2  
DTaP/DTP/DT/Td 1 4
2 5
3 6
Tdap 1  
Haemophilus Influenzee
type b (HIB)
1 3
2 4
Polio
(IPV/OPV)
1 3
2 4
Pneumocooal Conjugate
(PCV7/PCV13)
1 3
2 4
Rotavirus (RV1/RV5) 1 3
2  
Measles, Mumps, Rubella (MMR) 1 2
Varicella (Chickenpox) 1 2
History of Chickenpox Disease? If yes, date
VACCINES (Select Type) DATE ADMINISTERED
Hepatitis A
(Hep A)
1 2
Influenza (IIV/LAIV) 1 3
2 4
Meningococcal (MCV4/MPSV4) 1 2
Human Papillomavirus
(HPV9/HPV4/HPV2)
1 3
2  
OTHER Vaccines
Specify Date & Type
Type of Vaccine(s) Date of Vaccine(s)
1
2
3
Indicate and attach physician diagnosis or laboratory evidence of immunity as applicable
* NOTE: According to Public Act 368 of 1978, any child enrolling in a Michigan school for the first time must be adequately immunized, vision tested and hearing tested. Exemptions to these requirements are granted for medical, religious and other objections, provided that the waver forms are properly prepared, signed and delivered to school administrators. Forms for these exemptions are available at your provider office for medical waiver forms and through your local health department for nonmedical waiver forms.
Parent/Gauardian refused immunizations:
 
I certify that the Immunization dates are true to the best of my knowledge
 
Health Professional's Signature ________________________________________________________   Title ______________________________________   Date ______/______/______
 
Yes No SECTION IV - RECOMMENDATIONS
  (Required for Child Care and Head Start/Early Head Start)
 
Is there any defect of vision, hearing or other condition for which the school could help by seating or other actions? If yes, please explain:
Should the child's activity be restricted because of any physical defect or illness?
If yes, check and explain degree of restriction(s):
Other Recommendations:
SECTION V - DENTAL EXAMIMATION AND RECOMMENDATIONS (OPTIONAL)
I have examined _________________________'s teeth. As a result of this examination, my recommendation for treatment is:
 
___________________________________________________________________________________________________________________________________
 
Dentist's Signature _________________________________________________________ Date ______/______/______
 
PHYSICIAN'S SIGNATURE
Examiner's Signature ______________________________   Date ______/______/______   Examiner's Name (Print or Type)   Degree or License ______________________________
 
Number & Street ______________________________   City ______________________________   State ____________   ZIP Code ____________   Telephone (_____)__________________
 

Information required for:

Early On - Hearing and Vision Status: Diagnosis: Health Status.

Child Care Licensing - Physical Exam, Restrictions, Immunizationss

Head Start/Early Head Start - Determination that child is up-to-date on a schedule of age-appropriate preventive and primary health care, including medical, dental, and mental health. The schedule must incorporate the well-child care visit required by EPSDT and the latest immunizations schedule recommended by the Centers of Disease Control and Prevention, State, tribal, and local authorities. An EPSDT well-child exam includes height, weight, and blood tests for anemia at regular intervals based on age.

Developed in Cooperation with the Department of Health and Human Services, Education, Michigan American Association of Pediatrics, Early Childhood Investment Corporation, Child Care Licensing, Head Start, Michigan State Medical Society, Michigan Association of Osteopathic Physicians and Surgeons.

MDHHS/BCAL 3305 (formerly OCAL 3305/BRS-3305)