Health Appraisal Form
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1
2Developed in Cooperation With:
HEALTH APPRAISAL
School
Departments of Consumer & Industry Services,
Children's Group
Community Health, and Education;
Child Care Center
Michigan State Medical Society;
Child Caring Institution
Michigan Association of Osteopathic Physicians and Surgeons
Other: ______________
Dear Parent or Guardian:
The following information is requested so that the school and parent can work together to meet the physical, intellectual, and emotional needs of the child. Fill out the information
requested in Section I. Section II may be certified by transcription of information from the certificate of immunization. The remaining sections (111, IV, V) 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
Sex
Date of Birth
Last
First
Middle
Address
Today’s Date
Number & Street
City
Zip
Parent’s or Guardian’s Name
Telephone (Home)
Last
First
Middle
Address
Telephone (Work)
Number & Street
City
Zip
SECTION I -- HEALTH HISTORY
SECTION II --IMMUNIZATIONS
Statements such as "UP TO DATE" or "COMPLETE" will not be accepted. Admission to
Is your child having any of the problems listed below?
Yes
No
school may be denied on the basis of this information. *
VACCINE
DATE ADMINISTERED
1. Allergies or reactions: (for example, food,
medication, or other)
Type
Mo/Day/Yr.
Type
Mo/Day/Yr.
DTaP/DTP/Td
2. Hay fever, asthma, or wheezing
(Specify Type)
1.
6.
3. Eczema or frequent skin rashes
2.
7.
4. Convulsions/Seizures
3.
8.
5. Heart trouble
4.
9.
6. Diabetes
5.
10.
7. Frequent colds, sore throats, earaches
Haemophilus
(4 or more per year)
influenzae type b
1.
3.
(HIB)
8. Trouble with passing urine or bowel movements
2.
4.
POLIO IPV/OPV
9. Shortness of breath
(Specify Type)
1.
4.
10. Speech problems
2.
5.
11. Menstrual problems
3.
Note: If Measles, Rubella, or Mumps vaccines were given before 12 months of age, the
12. Dental problems: date of last examination:
dosage must be repeated.
13. Other
MMR
1.
2.
Varicella
(Chickenpox)
1.
2.
Please explain any problem areas identified above:
Hepatitis B HBV
1.
3.
2.
Pneumococcal
Conjugate (PCV)
1.
3.
2.
4.
Other Vaccines
Indicate physician diagnosis
or laboratory evidence of
immunity as applicable
VACCINES WAIVED DUE TO
REACTIONS/CONTRAINDICATIONS/
RELIGIOUS OBJECTIONS
I certify that the immunization dates are true to the best of my knowledge
Does your child take any medications regularly?
Yes
No
If yes, what medication?
Reason for Medication:
Parent’s Signature:
Validating Signature
Title
Date
*According to Act 368, Public Acts 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 waiver forms are properly prepared, signed, and delivered to school administrators.
Forms for these exemptions are available at your school or local health department.
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