E School E children`s Group El ctrito care center n Child Caring

E School
Group
E children's
El ctritocarecenter
n ChildCaringInstitution
E other:
HEALTH APPRAISAL
Developedin CooperationWth:
Departmentof HumanServices,
Departmentsof CommunityHealth,and Education;
MichiganStateMedicalSociety;
MichiganAssociationof OsteopathicPhysiciansand Surgeons
Dear Parentor Guardian: The foltowng informationis rquested so that the school and parent can worf together to meet the physical,inte
out the information requested in Seciioi l. Sedion ll may be certifed by transcription of information tom the certifcate of immunization. The remaining se
mmDleted bv a doctor. nurse. and dentist. (BE SURE TO BRING YOUR CHILD'S IMMUNIZATION RECORDS TO THE EXAMINATION.)
ons (1
PERSONAL
Sex
Name
Child's
First
Last
DateofBirfl
Middle
TodaYs
Date_
Address
zip
City
Number
&Street
(Home)
Telephone
Name
ParentsorGuardian's
First
Middle
(Work)
Telephone
Address
City
Number
& Street
sEcTtoNlt -tMMuNlzATloNs
SECTIONI - HEALTHHISTORY
child
of fie
ZiP
Admission
b school
willnotbeaccepted.
or"COMPLETE'
suchas"UPT0 DATE"
Statements
lisbdbelow?
(forexample,
{00d,medication,
0t other)
1. Allergies
orreactions:
orwheezing
2. Hayfever,
asthma,
skinrashes
3. Eczema
orfrequent
7. Frequent
colds,sorchroats,earaches
wifi passing
urineor bowelmovernents
8. Trcuble
0fage,thedosage
vaccines
weregivenbebre12 months
Rubella,
or Mumps
Note:lf Measles,
12. DentalDroblems:
date0f lastexamination:
above:
Please
explain
anyproblem
ateasidentified
diagnosis
or laborabry
of immunity
as
evidence
regularly?
Doesyourchildtskeanymedica$ons
li yes,whatmedication?
EYesENo
datesa€ fue tothebestof myknowledge
I certifythattheimmunization
Reason
br Medication:
Signaue:
Parents
lyimmunl
'AmrdingioAct368,PublicAclsof1978,anychildenDllinginaMicfiiganschoolforthefiFttimemustbeadequa
gGntedf; medi€t, Eligious,and otherobieciionsprvided thatwai r foms aB pr
lo€l healthdsartmenl
(
SECTIONIlI - PHYSICALEXAMINATION,
INSPECTION,
TESTS,AND MEASUREMENTS
EXAMINATIONS
AND/ORINSPECTIONS
ESSENTIALFINDINGSDEVIATINGFROMNORMALAND/ORRECOMMENDATIONS
EYes ENo
E OcularMusde
E Yes E t'lo
E Albumin
Date
E ottrer_
Date_
E Microscopic
E Yes E No
E oher_
Date
EYes ENo
Date
Readind
ESSENTIALFINDINGSDEVIATINGFROMNORMALAND/ORRECOMMENDATIONS
TuberculinTest (if given)
Type-
n Negative
tvls thereanydefectofvision,hearing,
or ofiercondition
forwhichtheschoolcouldhelpbyseating
oroheraction? E Yes E No
lf yes,please
explain:
degreeof restiction:
Should
fie studentsactivitybeEstrictedbecause
of anyphysical
defector illness?E Yes E No lf yes,checkbelowandexplain
E Classroom
EJ€miners
signature
Number
& Sieet
COMMENTS
E Plavoround
[-'l Gvmnasium
f-'l Swimmino
Pool
EcomDetitive
Soorts
[f Camo E Other
(printortype)
Name
Examiners
Date
City
Degree
0r License
Zip
Telephone