Form Mdch Bcal 3305 is a new medical marijuana form that was released by the Michigan Department of Health and Human Services on March 1, 2017. The form is designed to improve patient access to medical marijuana, and make it easier for patients and caregivers to register with the state. The new form can be downloaded from the department's website, and must be used for all new medical marijuana registrations. Patients who are already registered do not need to use the new form.
You will discover details about the type of form you wish to fill out in the table. It can tell you the span of time you'll need to complete form mdch bcal 3305, exactly what parts you will have to fill in and a few additional specific facts.
Question | Answer |
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Form Name | Form Mdch Bcal 3305 |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names |
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, First, Middle) |
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DATE OF BIRTH (mm/dd/yy) |
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ADDRESS (Number & Street) |
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TODAY’S DATE (mm/dd/yy) |
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PARENT/GUARDIAN (Last, First, Middle) |
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HOME TELEPHONE NUMBER |
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ADDRESS (Number & Street) |
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WORK TELEPHONE NUMBER |
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SECTION I - HEALTH HISTORY
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RESOLVED |
# Is your child having any of the problems listed below? |
Birth History: |
hh h 1 Allergies or Reactions (for example, food, medication or other)
hh h 2 Hay Fever, Asthma, or Wheezing
hh h 3 Exzema or Frequent Skin Rashes
hh h 4 Convulsions/Seizures
hh h 5 Heart Trouble
hh h 6 Diabetes
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Frequent Colds, Sore Throats, Earaches (4 or more per year) |
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Are there any current or past diagnosis(es) h Yes h No |
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Trouble with Passing Urine or Bowel Movements |
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If yes, please describe: |
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Shortness of Breath |
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hh h 10 Speech Problems
hh h 11 Menstrual Problems
h h h 12 Dental Problems: Date of Last Exam |
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hh h Other (please describe):
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Does your child take any medication(s) regularly? |
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If yes, list medications: |
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Reason for Medication |
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Was the health history reviewed by a health professional? |
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Parent/Guardian Signature |
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h Yes h No |
Examiner’s Initials: |
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SECTION II - PHYSICAL EXAMINATION, INSPECTION, TESTS AND MEASUREMENTS
Required for Child Care and Head Start / Early Head Start
Tests and Measurements
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Was child tested for: |
Test results: |
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VISION |
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Date: |
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HEARING |
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Other: |
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URINALYSIS |
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Date: |
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BLOOD LEAD LEVEL |
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Level |
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Essential Findings Deviating from Normal:
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REFERRED |
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UNDER CARE |
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Was child tested for: |
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Test results: |
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NORMAL |
REFERRED |
UNDER CARE |
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Visual Acuity |
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HEIGHT & WEIGHT |
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Height |
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Muscle Imbalance |
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Weight |
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Other: |
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Other |
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Audiometer |
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HEMOGLOBIN / HEMATOCRIT |
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Sugar |
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BLOOD PRESSURE |
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Reading: |
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TUBERCULIN |
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Type: |
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Albumin |
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Microscopic |
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Date: |
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Neg.: h Pos.: h |
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NOTE: Blood lead level required for all children enrolled in Medicaid must be tested |
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ug/dl |
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at one and two years of age, or once between three and six years of age if not |
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previously tested. All children under age six living in |
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at the same intervals as listed above. |
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Examinations and/or Inspections
Exam Date: |
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Page 1 of 2 |
February 2011 |
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 (Circle Type) |
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DATE ADMINISTERED |
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VACCINES (Circle Type) |
DATE ADMINISTERED |
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MM/DD/YYYY |
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MM/DD/YYYY |
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Hepatitis B |
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Hepatitis A (Hep A) |
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(Hep B) |
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Influenza TIV/LAIV |
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DTaP/DTP/DT/Td |
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Meningococcal MCV4 / MPSV4 |
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3 |
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Human Papillomavirus |
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(HVP4/HPV2) |
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Tdap |
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Haemophilus Influenzae |
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Type of Vaccine(s) |
Date of Vaccine(s) |
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OTHER Vaccines |
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type b (HIB) |
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Specify Date & Type |
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Polio - IPV / OPV |
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Pneumococcal Conjugate |
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Indicate and attach physician diagnosis or laboratory evidence of immunity as applicable |
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(PCV7/PCV13) |
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*NOTE: According to Public Act 368 of 1978, any child enrolling in a Michigan school for |
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Rotavirus (RV1/RV5) |
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the first time must be adequately immunized, vision tested and hearing tested. |
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Exemptions to these requirements are granted for medical, religious and other |
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objections, provided that the waiver forms are properly prepared, signed and |
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Measles,Mumps, Rubella (MMR) |
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delivered to school administrators. Forms for these exemptions are available at |
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your child’s school or local health department. |
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Varicella (Chickenpox) |
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History of Cickenpox Disease? h Yes |
h No |
If yes, date: |
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Parent/Guardian refused immunizations: h |
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I certify that the immunization dates are true to the best of my knowledge |
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Health Professional’s Signature |
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Title |
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Date |
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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): |
h Classroom h Playground h Gymnasium h Swimming Pool h Competitive Sports h Other |
Other Recommendations
SECTION V - DENTAL EXAMINATION AND RECOMMENDATIONS (OPTIONAL)
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I have examined |
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child’s name |
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Dentist’s Signature |
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Date |
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PHYSICIAN’S SIGNATURE |
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Examiner’s Signature |
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Examiner’s Name (Print or Type) |
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Degree or License |
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MI |
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Number & Street |
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City |
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ZIP Code |
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Telephone |
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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
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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.
MDCH/BCAL 3305 (formerly OCAL |
Page 2 of 2 |
Rev. February 2011 |