Form Mdch Bcal 3305 ≡ Fill Out Printable PDF Forms Online

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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
Form Name	Form Mdch Bcal 3305
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names

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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

YES

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

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

hh 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

NO	YES	Was child tested for:	Test results:
		VISION

h h
Date:	/	/	Other:
HEARING
h h			Other:
h h
Date:	/	/
URINALYSIS
h h
Date:	/	/
BLOOD LEAD LEVEL
h h			Level
h h
Date:	/	/

Essential Findings Deviating from Normal:

NORMAL

REFERRED

UNDER CARE

YES

Was child tested for:

Test results:

NORMAL

REFERRED

UNDER CARE

Visual Acuity

HEIGHT & WEIGHT

Height

Muscle Imbalance

Weight

Other:

Other

Audiometer

HEMOGLOBIN / HEMATOCRIT

]

Sugar

BLOOD PRESSURE

Reading:

TUBERCULIN

Type:

Albumin

Microscopic

Date:

Neg.: h Pos.: h

[

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:

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

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)				DATE ADMINISTERED			VACCINES (Circle Type)	DATE ADMINISTERED
VACCINES (Circle Type)				MM/DD/YYYY			VACCINES (Circle Type)		MM/DD/YYYY
				MM/DD/YYYY					MM/DD/YYYY
	Hepatitis B		1		3		Hepatitis A (Hep A)	1		2

	(Hep B)		2				Inﬂuenza TIV/LAIV	1		3

			1		4			2		4
			1		4			2		4

	DTaP/DTP/DT/Td		2		5		Meningococcal MCV4 / MPSV4	1		2

			3		6		Human Papillomavirus	1		2
							(HVP4/HPV2)
	Tdap		1				(HVP4/HPV2)	2		3

	Haemophilus Inﬂuenzae		1		3			Type of Vaccine(s)		Date of Vaccine(s)
							OTHER Vaccines
	type b (HIB)		2		4		OTHER Vaccines	1
							Specify Date & Type
	Polio - IPV / OPV		1		3		Specify Date & Type	2

			2		4			3

	Pneumococcal Conjugate		1		3	Indicate and attach physician diagnosis or laboratory evidence of immunity as applicable
	(PCV7/PCV13)
	(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
			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 child’s school or local health department.
	Varicella (Chickenpox)		1		2		your child’s school or local health department.
	Varicella (Chickenpox)		1		2

History of Cickenpox 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

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

(

)

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 schedule of well-child care 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 and 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.

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

Page 2 of 2

Rev. February 2011

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