Form Mdch Bcal 3305 PDF Details

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.

QuestionAnswer
Form NameForm Mdch Bcal 3305
Form Length2 pages
Fillable?Yes
Fillable fields139
Avg. time to fill out28 min 18 sec
Other namesHealth Appraisal 1f18s4s webadvisor ohlone form

Form Preview Example

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)

 

 

DATE OF BIRTH (mm/dd/yy)

 

 

 

 

/

/

 

 

 

 

ADDRESS (Number & Street)

(City)

(ZIP Code)

TODAY’S DATE (mm/dd/yy)

 

MI

 

 

/

/

 

 

 

 

PARENT/GUARDIAN (Last, First, Middle)

 

 

HOME TELEPHONE NUMBER

 

 

 

(

)

 

 

 

 

 

ADDRESS (Number & Street)

(City)

(ZIP Code)

WORK TELEPHONE NUMBER

 

MI

 

(

)

 

 

 

 

 

 

 

SECTION I - HEALTH HISTORY

<![endif]>Yes

<![endif]>No

<![endif]>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 Eczema or Frequent Skin Rashes

hh h 4 Convulsions/Seizures

hh h 5 Heart Trouble

hh h 6 Diabetes

h h h

7

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

 

Are there any current or past diagnosis(es) h  Yes    h  No

h h h

8

Trouble with Passing Urine or Bowel Movements

 

If yes, please describe:

h h h

9

Shortness of Breath

 

 

hh h 10 Speech Problems

hh h 11 Menstrual Problems

h

h

h

12 Dental Problems:  Date of Last Exam

/

/

 

h

h

h

Other (please describe):

 

 

 

 

 

 

 

 

 

 

 

 

h h

Does your child take any medication(s) regularly?

 

 

[

If yes, list medications:

 

 

 

 

Reason for Medication

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

 

Was the health history reviewed by a health professional?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Parent/Guardian Signature

Date

 

h  Yes    h  No

Examiner’s Initials:

 

 

SECTION II - PHYSICAL EXAMINATION, INSPECTION, TESTS AND MEASUREMENTS

Required for Child Care and Head Start / Early Head Start

Tests and Measurements

<![endif]>No Yes

Was child tested for:

Test results:

 

VISION

 

h h

 

 

 

Date:

 

/

/

Other:

HEARING

 

 

 

h h

 

 

Other:

 

 

 

Date:

 

/

/

 

URINALYSIS

 

 

 

h h

 

 

 

Date:

 

/

/

 

BLOOD LEAD LEVEL

 

 

h h

 

 

Level

 

 

 

Date:

 

/

/

 

  Essential Findings Deviating from Normal:

 

<![endif]>Normal

<![endif]>Referred

<![endif]>Under Care

<![endif]>No

<![endif]>Yes

Was child tested for:

 

Test results:

 

 

 

 

<![endif]>Normal

<![endif]>Referred

<![endif]>Under Care

Visual Acuity

 

 

 

h

h

HEIGHT & WEIGHT

 

 

 

Height

 

 

 

 

 

 

 

Muscle Imbalance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Weight

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

h

h

Other:

 

 

 

 

 

Other

 

 

 

 

 

 

 

Audiometer

 

 

 

h

h

HEMOGLOBIN / HEMATOCRIT

 

 

 

 

]

 

 

 

 

 

 

Sugar

 

 

 

h

h

BLOOD PRESSURE

 

 

 

Reading:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TUBERCULIN

 

 

 

 

Type:

 

 

 

 

 

 

 

 

Albumin

 

 

 

h

h

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Microscopic

 

 

 

 

 

Date:

/

/

 

 

Neg.:  h    Pos.:  h

 

 

mm

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

[

NOTE:  Blood lead level required for all children enrolled in Medicaid must be tested

ug/dl

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

Exam Date: 

/ 

/

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

Page 1 of 2

Rev. July 2015

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)

 

DATE ADMINISTERED

 

 

VACCINES (Circle Type)

DATE ADMINISTERED

 

 

 

MM/DD/YYYY

 

 

 

 

MM/DD/YYYY

 

 

 

Hepatitis B

1

 

3

 

 

Hepatitis A (HepA)

1

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(HepB)

2

 

 

 

 

Influenza (IIV/LAIV)

1

 

 

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

4

 

 

2

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DTaP/DTP/DT/Td

2

 

5

 

 

Meningococcal (MCV4 / MPSV4)

1

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

6

 

 

Human Papillomavirus

1

 

 

3

 

 

 

 

 

 

 

 

 

(HPV9/HPV4/HPV2)

 

 

 

 

 

 

 

Tdap

1

 

 

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Haemophilus Influenzae

1

 

3

 

 

 

Type of Vaccine(s)

Date of Vaccine(s)

 

 

 

 

 

 

 

OTHER Vaccines

 

 

 

 

 

 

 

type b (HIB)

2

 

4

 

 

1

 

 

 

 

 

 

 

 

 

 

 

 

Specify Date & Type

 

 

 

 

 

 

 

Polio

1

 

3

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(IPV/OPV)

2

 

4

 

 

 

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pneumococcal Conjugate

1

 

3

 

Indicate and attach physician diagnosis or laboratory evidence of immunity as applicable

 

(PCV7/PCV13)

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

4

 

*NOTE: According to Public Act 368 of 1978, any child enrolling in a Michigan school for

 

 

 

 

 

 

 

Rotavirus (RV1/RV5)

1

 

3

 

 

the first time must be adequately immunized, vision tested and hearing tested.

 

 

 

 

 

 

 

Exemptions to these requirements are granted for medical, religious and other

 

 

2

 

 

 

 

 

 

 

 

objections, provided that the waiver forms are properly prepared, signed and

 

 

 

 

 

 

 

Measles,Mumps, Rubella (MMR)

1

 

2

 

 

delivered to school administrators. Forms for these exemptions are available

 

 

 

 

 

 

 

at your provider office for medical waiver forms and through your local health

 

Varicella (Chickenpox)

1

 

2

 

 

 

 

department for nonmedical waiver forms.

 

 

 

 

 

 

 

 

 

 

 

 

 

History of Chickenpox Disease?    h  Yes    h  No      If yes, date:

 

Parent/Guardian refused immunizations:  h

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I certify that the immunization dates are true to the best of my knowledge

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/ 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health Professional’s Signature

 

Title

 

 

 

Date

 

 

<![endif]>No Yes

h h

h h

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)

 

I have examined

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

child’s name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

  /

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dentist’s Signature

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHYSICIAN’S SIGNATURE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Examiner’s Signature

 

 

 

Date

Examiner’s Name (Print or Type)

 

 

 

 

 

 

 

Degree or License

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MI

 

 

(

 

 

   

)

 

 

 

 

 

 

 

 

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 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.

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

Page 2 of 2

Rev. July 2015

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entering details in Form Mdch Bcal 3305 part 1

In the ReasonforMedication, Ifyeslistmedications, ParentGuardianSignature, Date, hYeshNo, ExaminersInitials, TestsandMeasurements, sWaschildtestedfor, Testresults, amroN, derrefeR, eraCrednU, sWaschildtestedfor, Testresults, and amroN area, put in writing your details.

stage 2 to finishing Form Mdch Bcal 3305

The application will require for more info as a way to effortlessly fill out the part VACCINESCircleType, DATEADMINISTERED, MMDDYYYY, HepatitisB, HepB, DTaPDTPDTTd, Tdap, HaemophilusInfluenzae, typebHIB, Polio, IPVOPV, PneumococcalConjugate, PCVPCV, RotavirusRVRV, and MeaslesMumpsRubellaMMR.

Filling in Form Mdch Bcal 3305 stage 3

You need to define the rights and responsibilities of all parties in box OtherRecommendations, Ihaveexamined, childsname, DentistsSignature, Date, PHYSICIANSSIGNATURE, ExaminersSignature, Date, ExaminersNamePrintorType, DegreeorLicense, NumberStreet, City, ZIPCode, Telephone, and Informationrequiredfor.

Form Mdch Bcal 3305 OtherRecommendations, Ihaveexamined, childsname, DentistsSignature, Date, PHYSICIANSSIGNATURE, ExaminersSignature, Date, ExaminersNamePrintorType, DegreeorLicense, NumberStreet, City, ZIPCode, Telephone, and Informationrequiredfor blanks to insert

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