Health Appraisal Form (Page 2 of 2) in pdf

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.*

DATE ADMINISTERED

VACCINES

MM/DD/YYYY

Hepatitis B

Hepatitis A (Hep A)

(Hep B)

Influenza TIV/LAIV

DTaP/DTP/DT/Td/Tdap

Meningococcal MCV4 / MPSV4

Human Papillomavirus

(Circle Type)

(HPV)

Haemophilus Influenzae

Type of Vaccine(s)

Date of Vaccine(s)

OTHER Vaccines:

type b (HIB)

Polio – IPV / OPV

Specify Date & Type

(circle type)

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

Pneumococcal Conjugate (PCV7)

*NOTE: 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.

Rotavirus (Rota)

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

Measles, Mumps, Reubella

(MMR)

your child’s school or local health department.

Varicella (Chickenpox)

History of Chickenpox Disease?

Yes

If yes, date:

Parent/Guardian refused immunizations:

I certify that the immunization dates are true to the best of my knowledge:

____________________________________________________________________

__________________________________

_______/_______/_________

Health Professional’s Signature

Title

Date

SECTION IV – RECOMMENDATIONS

No Yes

(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):

Classroom

Playground

Gymnasium

Swimming Pool

Competitive Sports

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

________________________________________________________________

___________________________________________ MI _______________ (_____) ______________

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 at 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

Rev. September 2009

Page 2 of 2 - 09.10.2010

MDCH/BCAL-3305 (formerly OCAL3305/BRS-3305)