Health Appraisal
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1Health Appraisal
Examination Date
Child’s Name – Last Name:
Female
Male
First Name:
Date of Birth:
Gender
Home Address:
Home Phone No.:
Alternate Phone No.:
Parent/Guardian Name:
Allergies and/or Special Needs (List):
Does your child have health insurance? Yes No
Health Insurance Carrier’s Name and Member ID No.:
I give my consent for my child’s Health Care Provider and Head Start discuss the information on this form. Yes
No
Signature:
Date:
Medication(s):
MO/DAY/YR
MO/DAY/YR
SECTION II – IMMUNIZATIONS
VACCINE TYPE
Statement such as “
” or “
” will not be accepted
*MMR Measles, Mump, Rubella*
1.
2.
UP-TO-DATE
COMPLETE
Admission to school may be denied on the basis of this information
VACCINE
DATE ADMINISTERED
Varicella (Chicken Pox)
1.
2.
(Specify Type)
Yes No Date: _______
MO/DAY/YR
MO/DAY/YR
History of Chicken Pox Disease
Dta/DTP/TD
1.
6.
Hepatitis B (HBV)
1.
3.
2.
7.
2.
4.
3.
8.
Pneumococcal Conjugate
1.
3.
PCV
4.
9.
2.
4.
5.
10.
Other Vaccinations (Specify)
1.
3.
Haemophillus influenza type
1.
3.
Note If Measles, Mumps, Rubella (MMR) & Chicken Pox vaccines were given before 12
b
months of age, the dosage must be repeated.
(HIB)
Indicate physician’s diagnosis or laboratory evidence of immunity as applicable
2.
4.
1.
4.
POLIO – IPV – OPV
2.
5.
VACCINES WAIVED DUE TO REACTIONS/CONTRADICTIONS _________________
3.
6.
RELIGIOUS OBJECTIONS __________________________________________________
Type of Screening
Date Performed
Record Number
Type of Screening
Date Performed
Hgb/HCT
Hearing
Passed
Failed
Lead
Vision
Passed
Failed
Blood Pressure
TB/Chest X-Ray
Neg.
Pos.
/
Sickle Cell, If Positive
Trait
Disease
Ht/Wt
Normal
Under
Referred
Normal
Under
Referred
Normal
Under
Referred
Care
Care
Care
Eyes
Lungs
Skin
Ear/Nose/Throat
Breast
Extremities
Teeth
Abdomen
Spine
Thyroid
Genitalia
General Nutrition
Lymphatic System
Rectal
Speech
Heart/Vascular System
Other
Essential Findings Deviating from the Normal and/or Recommendations:
Examiner’s Name in Print:
Telephone No:
Examiner’s Signature:
Medical Follow-up Indicated
Office/Clinic Address:
City:
State:
Zip:
Yes
No
.
Developed in Cooperation with The Michigan Department of Community Health, Michigan Department of Day Care Licensing, Michigan State Medical Society
6/
06
Funded by the US Department of Health and Human Services through the City of Detroit Department of Human Services
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Parent category: Medical