Health Appraisal Form

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

Date of Birth

Address (Number & Street)

City

State

Zip

Today's Date

Parent / Guardian (Last Name)

First Name

Middle

Home Telephone Number

Address (Number & Street)

City

State

Zip Code

Work Telephone Number

Section I - Health History

Is your child having any of the problems listed below?

1. Allergies or Reactions (for example, food, medication or other)

Yes No Resolved

2. Hay Fever, Asthma, or Wheezing

Yes No Resolved

3. Eczema or Frequent Skin Rashes

Yes No Resolved

4. Convulsions / Seizures

Yes No Resolved

5. Heart Trouble

Yes No Resolved

6. Diabetes

Yes No Resolved

7. Frequent Colds, Sore Throats, Earaches (4 or more per year)

Yes No Resolved

8. Trouble with Passing Urine or Bowel Movements

Yes No Resolved

9. Shortness of Breath

Yes No Resolved

10. Speech Problems

Yes No Resolved

11. Menstrual Problems

Yes No Resolved

12. Dental Problems

Yes No Resolved

(For dental Problem) Date of Last Exam

Other (Please describe)

Does your child take any medications regularly?

Yes No

Reason for Medication

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Parent / Guardian Signature

Date

Birth History

Are there any current or past diagnosis(es

Yes No

If yes, please describe:

If yes, list medications:

Was the health history reviewed by a health professional?

Yes No

Examiner's Initials

Section ll - PHYSICAL EXAMNIATION, INSPECTION, TESTS AND MEASUREMENTS

Request for Child Care and head Start / Early Head Start

Was child tested for

Vision

Yes No

Date

Hearing

Yes No

Date

Urinalysis

Yes No

Date

Blood Lead Level

Yes No

Date

Test Results

Visual Acuity

Normal Referred Under Care

If Other, Please list

Muscle Imbalance

Normal Referred Under Care

If Other, Please list

Audio Meter

Normal Referred Under Care

If Other, Please list

Sugar

Normal Referred Under Care

Albumin

Normal Referred Under Care

Microscopic

Normal Referred Under Care

Level (ug/dl)

Was your child tested for

Test Results

Height & Weight

Yes No

Height

Normal Referred Under Care

Other

Weight

Normal Referred Under Care

Hemoglobin / Hematocrit

Yes No

Other

Blood Pressure

Yes No

Tuberculin

Yes No

Reading

Date

Type

Negative

Positive

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

Section lll - 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

Hepatitis B

(Hep B)

Date Administered

Vaccines

DTaP/DTP/DT/Td

Vaccines

Tdap

Vaccines

Haemophilus Influenzae

type b (HIB)

Vaccines

Polio

(IPV/OPV)

Vaccines

Pneumococcal Conjugate

(PCV7/PCV13)

Vaccines

Rotavirus (RV1/RV5)

Measles,Mumps, Rubella (MMR)

Measles

Mumps

Rubella (MMR)

Vaccines

Varicella (Chickenpox)

History of Chickenpox Disease?

Yes

If yes, Date

Vaccines

Hepatitis A (Hep A)

Vaccines

Influenza (TIV/LAIV)

Vaccines

Meningococcal (MCV4 / MPSV4)

Vaccines

Human Papillomavirus

(HPV4/HPV2)

OTHER Vaccines Specify Date & Type

Add new row

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 waiver forms are properly prepared, signed and delivered to school administrators. Forms for these exemptions are available at your child’s school or local health department.

Parent / Guardian refused immunizations

Health Professional's Signature

Title

Date

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?

Yes No

If yes, please explain

Should the child’s activity be restricted because of any physical defect or illness?

Yes No

If yes, check and explain degree of restriction(s):

Classroom

Playground

Gymnasium

Swimming Pool

Competitive Sports

Other

Other Recommendations

Section V - Dental Examination and recommendations (Optional)

I have examined

's teeth. As a result of this examination, my recommendation for treatment is

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Dentist's Signature

Date

Physician's Signature

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Examiner's Signature

Date

Examiner’s Name

Degree or License

Number & Street

City

Zip Code

Telephone

Information required for:

Early On - Hearing and Vision Status; Diagnosis; Health Status

Child Care Licensing - Physical Exam, Restrictions, Immunizations

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 for 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 Departments of Human Services, Education, Community Health, 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.

Your information will be encrypted.