Michigan Health Care Appraisal
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1HEALTH CARE APPRAISAL
Michigan Department of Licensing and Regulatory Affairs, Bureau of Community and Health Systems
Licensee Name
Resident Name
Case Number
AFC Facility Name
Facility License Number
Worker Name / Load Number
Worker Phone Number
Release of General Medical Information: By signing this form, I understand that I am authorizing the release of medical information concerning me to the licensee and licensee's staff,
the responsible agency, and the Michigan Department of Licensing and Regulatory Affairs, Bureau of Community and Health Systems for the purpose of providing appropriate care to me
and determining compliance with licensing rules.
Signature of Resident / Legal Guardian
Title
Date
Release of HIV/AIDS Information: By signing this form, I understand that I am authorizing the release of medical information concerning me, including information regarding Acquired Immunodefi ciency
Syndrome (AIDS), or Human Immunodefi ciency Virus (HIV), if applicable, to the licensee and licensee's staff, the responsible agency, and the Michigan Department of Licensing and Regulatory Affairs,
Bureau of Community and Health Systems, for the purpose of providing appropriate care to me and determining compliance with licensing rules.
Signature of Resident / Legal Guardian
Title
Date
1. Height
2. Weight
3. Ideal Weight Range
4. Blood Pressure
5. Age
6. Sex
MALE
FEMALE
15. Physical Exam:
7. Diagnoses
**
TYPE
NORM
ABN
DEFERRED
1. Skin
8. Current Medications and Instructions
2. Ears
3. Nose
4. Throat
5. Mouth
6. Neck
7. Breasts
8. Chest
9. Lungs
10. Heart
11. Abdomen
12. Extremities
Upper
9. Allergies
Lower
13. Feet / Toes
14. Lymph Nodes
10. General Appearance
15. Genitalia
16. Testes
17. Spine
11. Mental / Physical Status and Limitations
18. Refl exes
19. Neurological
20. Rectal
12. Mobility / Ambulatory Status:
21. Sexually Transmitted Diseases
YES
NO
Fully Ambulatory
Uses Walker
22. Other:
Uses Cane
Uses Wheelchair
13. Susceptibility to Hyper / Hypothermia and Related Limitations
**Deferred, as used here, means examination considered but postponed
Explanation of Abnormalities/Treatment Ordered
14. Special Dietary Instructions and Recommended Caloric Intake
16. Other Health-Related Information or Concerns
M.D./D.O./P.A. or R.N.
(Please Print Name)
Signature
City
State
Zip Code
Address
Title
Date of Signature
Date of Exam
AUTHORITY:
1979 PA 218
R 400.14301(10) and R 400.15301(10)
COMPLETION:
Required.
R 400.14310 and R 400.15310
LARA is an equal opportunity employer/program.
:
CONSEQUENCE
Violation of AFC Licensing Rules.
R 400.14313(3) and R 400.15313(3)
BCAL-3947 (Rev. 1-16) Previous editions may be used.
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Parent category: Medical