HEALTH 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 (Last, First, Middle) DATE OF BIRTH (mm/dd/yy)
/ /
ADDRESS (Number & Street) (City) (ZIP Code) TODAY’S DATE (mm/dd/yy)
MI / /
PARENT/GUARDIAN (Last, First, Middle) HOME TELEPHONE NUMBER
( )
ADDRESS (Number & Street) (City) (ZIP Code) WORK TELEPHONE NUMBER
MI ( )
SECTION I - HEALTH HISTORY
# Is your child having any of the problems listed below? Birth History:
h h h 1 Allergies or Reactions (for example, food, medication or other)
h h h 2 Hay Fever, Asthma, or Wheezing
h h h 3 Eczema or Frequent Skin Rashes
h h h 4 Convulsions/Seizures
h h h 5 Heart Trouble
h h h 6 Diabetes
h h h 7 Frequent Colds, Sore Throats, Earaches (4 or more per year) Are there any current or past diagnosis(es) h Yes h No
h h h 8 Trouble with Passing Urine or Bowel Movements If yes, please describe:
h h h 9 Shortness of Breath
h h h 10 Speech Problems
h h h 11 Menstrual Problems
h h h 12 Dental Problems: Date of Last Exam / /
h h h Other (please describe):
h h Does your child take any medication(s) regularly? If yes, list medications:
Reason for Medication [
/ / Was the health history reviewed by a health professional?
Parent/Guardian Signature Date h Yes h No Examiner’s Initials:
Yes
No
Resolved
SECTION II - PHYSICAL EXAMINATION, INSPECTION, TESTS AND MEASUREMENTS
Required for Child Care and Head Start / Early Head Start
Tests and Measurements
No
Yes
Was child tested for: Test results:
Normal
Referred
Under Care
Visual Acuity
Muscle Imbalance
Other:
Audiometer
Other:
Sugar
Albumin
Microscopic
Level ug/dl [
VISION
Date: / /
HEARING
Date: / /
URINALYSIS
Date: / /
BLOOD LEAD LEVEL
Date: / /
h h
h h
h h
h h
No
Yes
Was child tested for: Test results:
Normal
Referred
Under Care
Height
Weight
Other
]
Reading:
Type:
Neg.: h Pos.: h mm
HEIGHT & WEIGHT
Other:
HEMOGLOBIN / HEMATOCRIT
BLOOD PRESSURE
TUBERCULIN
Date: / /
h h
h h
h h
h h
NOTE: Blood lead level required for all children enrolled in Medicaid must be tested
at one and two years of age, or once between three and six years of age if not
previously tested. All children under age six living in high-risk areas should be tested
at the same intervals as listed above.
h h
Examinations and/or Inspections
Essential Findings Deviating from Normal:
Exam Date: / /
MDHHS/BCAL-3305 (formerly OCAL 3305/BRS-3305)
Page 1 of 2
Rev.