MDHHS-3305, HEALTH APPRAISAL

MDHHS-3305, HEALTH APPRAISAL
Michigan Department of Health and Human Services (MDHHS) (Revised 7-24) 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 1. Section 4 may be certified by the transcription of information from the certificate of immunization. The remaining sections are to be completed by a doctor, nurse, dentist, dental therapist, and dental hygienist.
BE SURE TO BRING YOUR CHILD'S IMMUNIZATION RECORDS TO THE EXAMINATION
Child's Name (Last, First, Middle)
Date of Birth (mm/dd/yy)

MonthDayYear
Date
Address (Number, Street, City, Zip Code)
Today's Date (mm/dd/yy)

MonthDayYear
Date
Parent/Guardian (Last, First, Middle)
Work Phone Number
Address (Number, Street, City, Zip Code)
Work Phone Number
Is your child having any of the problems listed below?

SECTION 2 - HEALTH HISTORY Is your child having any of the problems listed below?

	Yes	No	Resolved
Allergies or Reactions (for example, food, medication or other)
Anaphylaxis
Does your child take any medication(s) regularly
Hay Fever, Asthma or Wheezing
Eczema or Frequent Skin Rashes
Convulsions/Seizures
Heart Trouble
Diabetes
Frequent Colds, Sore Throats, Earaches (4 or more per year)
Trouble with Passing Urine or Bowel Movements
Shortness of Breath
Speech Problems
Menstrual Problems
Dental Problems
Other(describe)