southfieldpeds.com - Health Appraisal Form

HEALTH APPRAISAL

Michigan Department of Health & Human Services
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

First NameMiddle NameLast Name
ADDRESS

Number & Street

Street Address Line 2

CityState / Province

Postal / Zip Code
PARENT/GUARDIAN

First NameMiddle NameLast Name
ADDRESS

Number & Street

Street Address Line 2

CityState / Province

Postal / Zip Code
DATE OF BIRTH

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
TODAY’S DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
HOME TELEPHONE NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
WORK TELEPHONE NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
SECTION I - HEALTH HISTORY

Is your child having any of the problems listed below?

Rows	Yes	No	Resolved
1 Allergies or Reactions (for example, food, medication or other)
2 Hay Fever, Asthma, or Wheezing
3 Eczema or Frequent Skin Rashes
4 Convulsions/Seizures
5 Heart Trouble
6 Diabetes
7 Frequent Colds, Sore Throats, Earaches (4 or more per year)
8 Trouble with Passing Urine or Bowel Movements
9 Shortness of Breath
10 Speech Problems
11 Menstrual Problems
12 Dental Problems:

Dental Problems: Date of Last Exam

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Other (please describe):
Does your child take any medication(s) regularly?
If yes, list medications:
Reason for Medication
Birth History:
Are there any current or past diagnosis(es)
If yes, please describe:
Was the health history reviewed by a health professional?
Parent/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

HEALTH APPRAISAL