Health Appraisal Form – Fill Out and Use This PDF

Enter the child's name as Last, First, Middle.

Enter the Date of Birth as mm/dd/yy.

Enter the child's Address and the Parent/Guardian's Address as Number, Street, City, Zip Code.

Enter Today's Date as mm/dd/yy.

Enter the Parent/Guardian name as Last, First, Middle, then the Home/Cell Phone Number and the Work Phone Number.

For "Is your child having any of the problems listed below?", mark Yes, No or Resolved for each problem listed.

Enter the Birth History.

If yes to "Does your child take any medication(s) regularly?", list medications.

Enter the Reason for Medication.

For "Are there any current or past diagnosis(es)?", mark Yes or No and, if yes, describe.

Next to Dental Problems, enter the Date of Last Exam OR Date of Last Assessment.

For Other, describe.

Enter the Concussion History.

Mark Yes or No for "Was the health history reviewed by a health professional?" and enter the Examiner's Initials.

Section 3, Physical Examination, Inspection, Tests and Measurements, is Required for Child Care and Head Start / Early Head Start.

Under Test and Measurements, mark Yes or No for "Was child test for", enter the Tests and results, and mark Normal, Referred or Under Care.

For Vision, enter the Visual Acuity, the Date, the Muscle Imbalance and Other.

For Hearing, enter the Date; for Audiometer, OAE and Other, R= Right, L=Left.

For Urinalysis, enter Sugar, Albumin and Microscopic.

For Blood Lead Level, enter the Level in ug/dl and the Date.

Note on Blood Lead Level: All children in Medicaid need to be tested at 1 and 2 years of age, or once between 3 and 6 years of age if not previously tested. All children, regardless of Medicaid status, should be tested at those same ages if they live in an area where lead risk is high.

Enter the Height, the Weight, Other, Hemoglobin/Hematocrit and the Blood Pressure Reading.

Under Examinations and/or Inspections, enter the Essential Findings Deviating from Normal and the Exam Date.

In Section 4, Immunizations, statements such as "UP-TO-DATE" or "COMPLETE" will not be accepted, and admission to school may be denied based on this information.

For each vaccine, select the type and enter the Date Administered (mm/dd/yy).

Vaccines with a type to select: Polio (IPV/OPV), Rotavirus (RV1/RV5), Measles, Mumps, Rubella (MMR/MMRV), Varicella (Chickenpox) (Var, MMRV), Influenza (IIV/LAIV), Meningococcal (MCV4, Menabcwy) and Meningococcal B (Bexsero, Trumenba, Menabcwy).

Under Additional Vaccines, specify the Type of Vaccine(s) and the Date of Vaccine(s).

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

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 provider office for medical waiver forms and through your local health department for nonmedical waiver forms.

For History of Chickenpox Disease?, mark Yes or No and, if yes, enter the date.

If the Parent/Guardian refused recommended immunizations at visit, check the box.

Section 5, Recommendations, is Required for Child Care and Head Start/Early Head Start.

Mark Yes or No for "Is there any defect of vision, hearing, or other condition for which the school could help by seating or other actions?" and, if yes, explain.

Mark Yes or No for "Should the child's activity be restricted because of any physical defect or illness?" and, if yes, explain degree of restriction(s).

Check all that apply: Classroom, Playground, Gymnasium, Swimming Pool, Competitive Sports or Other.

Enter any Other Recommendations.

Enter the Child's Name and mark Dental Exam or Dental Assessment under Type of Service.

Under Findings (Check all that apply), mark No findings, Treated Decay or Untreated Decay.

Under Recommendations (Check one), mark Routine Care, Referral for dental treatment or Referral for urgent dental care.

Check one: Dentist, Dental Therapist or Dental Hygienist.

Print the Examiner's Name and enter the Degree or License and the Telephone Number.

Enter the Address, City and Zip Code; State is MI.

Section 2, Health History: sign on the Parent/Guardian Signature line and enter the Date. Immunization dates: the Health Professional signs on the Health Professional Signature line and fills in the Title and the Date. Section 6, Dental Exam or Assessment Recommendations: sign on the Provider Signature line and enter the Date. Section 7, Physician's Signature: sign on the Examiner's Signature line and enter the Date.

The Health Professional signs on the Health Professional Signature line, below "I certify that the immunization dates are true to the best of my knowledge".