Health Appraisal Form – Fill Out and Use This PDF

A Health Appraisal form is an essential tool designed to gather comprehensive health information about a child, allowing schools and parents to collaboratively address the child's physical, intellectual, and emotional needs. It encapsulates a wide array of data, including health history, immunization records, physical examination findings, and any additional health concerns that require attention, all aimed at ensuring a supportive and safe educational environment. Ensure your child's well-being and readiness for school by filling out the Health Appraisal form today – click the button below to get started.

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Health Appraisal Form PDF Details

The Health Appraisal form serves as a comprehensive tool designed to capture critical information regarding a child’s health and medical history, which is essential for schools to fulfill their role in supporting a child's overall wellbeing effectively. By requesting detailed information from parents or guardians about a child's health history, current health status, and immunizations, the form aids in identifying any physical, intellectual, and emotional needs a child may have. The form is divided into structured sections, which include the child’s personal information, a detailed health history questionnaire, physical examination findings, immunization records, and specific recommendations from healthcare professionals regarding any further medical, dental, or mental health care needs the child may have. With sections requiring completion by a doctor, nurse, or dentist, the form also mandates the presentation of the child's immunization record at the time of examination. Additionally, it covers the necessity for certain tests and measurements like vision and hearing, alongside a dental examination, to ensure a holistic understanding of the child’s health. This meticulously designed document not only facilitates the school's engagement with healthcare providers but also ensures adherence to health regulatory requirements, thereby playing a pivotal role in safeguarding children's health in an educational setting.

Question	Answer
Form Name	Health Appraisal Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	health form appraisal, mi health appraisal, bcal forms, michigan health appraisal

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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 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

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:

MDHHS/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
VACCINES (Circle Type)			MM/DD/YYYY			VACCINES (Circle Type)		MM/DD/YYYY
			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
		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				(HPV9/HPV4/HPV2)	2

	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	1		3		Specify Date & Type	2

	(IPV/OPV)	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 provider office for medical waiver forms and through your local health
	Varicella (Chickenpox)	1		2
	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

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 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.

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

Page 2 of 2

Rev. July 2015

How to Edit Health Appraisal Form Online for Free

You'll be able to fill in mi appraisal form effortlessly by using our online PDF tool. Our tool is consistently evolving to give the best user experience achievable, and that's thanks to our commitment to continuous development and listening closely to comments from users. Starting is effortless! Everything you need to do is take the next basic steps down below:

Step 1: Hit the orange "Get Form" button above. It will open up our pdf editor so that you could begin completing your form.

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It will be easy to complete the pdf with this detailed tutorial! Here's what you should do:

1. For starters, once filling in the mi appraisal form, start out with the section containing following blank fields:

health care appraisal completion process shown (portion 1)

2. Once your current task is complete, take the next step – fill out all of these fields - h h, Does your child take any, Reason for Medication, If yes list medications, ParentGuardian Signature, Date, Was the health history reviewed by, h Yes h No, Examiners Initials, SECTION II PHYSICAL EXAMINATION, Required for Child Care and Head, Tests and Measurements, o N, s e Y, and Was child tested for with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

s e Y, Examiners Initials, and o N inside health care appraisal

3. Your next step is usually straightforward - fill in all of the blanks in Microscopic, Date, Neg h Pos h, Level, ugdl, NOTE Blood lead level required for, h h, Date, BLOOD LEAD LEVEL, Date, Essential Findings Deviating from, Examinations andor Inspections, MDHHSBCAL formerly OCAL BRS, Page of, and Exam Date in order to complete this part.

Filling in section 3 in health care appraisal

4. This next section requires some additional information. Ensure you complete all the necessary fields - VACCINES Circle Type, DATE ADMINISTERED, MMDDYYYY, Hepatitis B, HepB, DTaPDTPDTTd, Tdap, Haemophilus Inﬂuenzae, type b HIB, Polio, IPVOPV, Pneumococcal Conjugate, PCVPCV, Rotavirus RVRV, and MeaslesMumps Rubella MMR - to proceed further in your process!

Writing segment 4 of health care appraisal

It is possible to get it wrong when completing the VACCINES Circle Type, consequently make sure to take a second look prior to deciding to finalize the form.

5. To finish your form, the final segment requires a number of additional fields. Entering Other Recommendations, I have examined, s teeth As a result of this, childs name, SECTION V DENTAL EXAMINATION AND, Dentists Signature, Date, PHYSICIANS SIGNATURE, Examiners Signature, Date, Examiners Name Print or Type, Degree or License, Number Street, City, and ZIP Code will conclude the process and you're going to be done very fast!

Stage # 5 for submitting health care appraisal

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Health Appraisal Form – Fill Out and Use This PDF

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