Health Appraisal Form
ADVERTISEMENT
1
2HEALTH 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: ____________________________________________________
_______________________________________
_______
Date of Birth: _____/_____/________
Last
First
Middle
Address: __________________________________________________
___________________________________ MI ________________
Today’s Date: _____/_____/________
Number & Street
City
ZIP Code
Parent/
Guardian: _______________________________________________________
_______________________________________
_______
Telephone:
(_____) _____________
Last
First
Middle
Home
Address: __________________________________________________
___________________________________ MI ________________
Telephone: (_____) ______________
Number & Street
City
ZIP Code
Work
SECTION I – HEALTH HISTORY
# Is your child having any of the problems listed below?
Birth History:
1 Allergies or Reactions (for example, food, medication or other)
2 Hay Fever, Asthma, or Wheezing:
3 Eczema or Frequent Skin Rashes
4 Convulsions/Seizures
5 Heart Trouble
6 Diabetes
7 Frequent Colds, Sore Throats, Earaches (4 or more per year)
Are there any current or past diagnosis(es):
Yes
No
8 Trouble with Passing Urine or Bowel Movements
If yes, please describe
9 Shortness of Breath
10 Speech Problems
11 Menstrual Problems
12 Dental Problems: Date of Last Exam: _____ / ____ / _____
Other (please describe): __________________________________
______________________________________________________
Does your child take any medication(s) regularly?
If yes, list medications:
Reason for medication:
Was the health history reviewed by a health professional?
__________________________________________________
____/____/____
Yes
No
Examiner’s Initials: ___________________________
Parent/Guardian Signature
Date
SECTION II – PHYSICAL EXAMINATION, INSPECTION, TESTS AND MEASUREMENTS
Required for Child Care and Head Start / Early Head Start
Tests and Measurements
Was child tested for:
Test results:
Was child tested for:
Test Results:
No Yes
No Yes
Visual Acuity
Height: ___________________
VISION
HEIGHT & WEIGHT
Muscle Imbalance
Weight: ___________________
Date: ______/______/______
Other:
Other: ____________________
Other:
HEMOGLOBIN / HEMATOCRIT
Audiometer
HEARING
Other:
BLOOD PRESSURE
Reading: _____________
Date: ______/______/______
Sugar
Type: ________________
URINALYSIS
TUBERCULIN
Albumin
Date: ______/______/______
_______
Date: ______/______/______
Neg.:
Pos.:
mm
Microscopic
NOTE: Blood lead level required for all children enrolled in Medicaid must be tested at one and
BLOOD LEAD LEVEL
two years of age, or once between three and six years of age if not previously tested. All
Level: ________ μg/dL
children under age six living in high-risk areas should be tested at the same intervals as listed
Date: ______/______/______
above.
Examinations and/or Inspections
Essential Findings Deviating from Normal:
Exam Date: ______/______/______
Page 1 of 2 - 09.10.2010
MDCH/BCAL-3305 (formerly OCAL3305/BRS-3305)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical