2014-2015 ECP-Grade 8 Health Appraisal Form

1250 Kensington Rd, Bloomfield Hills, MI 48304-3029
2014-2015 Student Health Appraisal
LAST
STUDENT
NAME:
FIRST
MIDDLE
STREET
STUDENT
ADDRESS:
SEX
GRADE
DATE OF BIRTH
CITY
AGE
ZIP
FATHER/GUARDIAN'S NAME
WORK PHONE
CELL PHONE
MOTHER/GUARDIAN NAME
WORK PHONE
CELL PHONE
HEALTH HISTORY
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Has your child had any of the problems listed below?
Birth History:
Allergies or Reactions (for example: food, medication or other)
_________________________________________________________________
Hay Fever, Asthma, or Wheezing
Eczema or Frequent Skin Rashes
_________________________________________________________________
Convulsions/Seizures
Heart Disease/Murmur
_________________________________________________________________
Diabetes
Frequent Colds, Sore Throats, Earaches (4 or more per year)
_________________________________________________________________
Trouble with Passing Urine or Bowel Movements
Shortness of Breath
Are there any current or past diagnosis(es):
Speech Problems
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Yes
No
If yes, please describe:
Menstrual Problems
Frequent Nosebleeds
_________________________________________________________________
Frequent Headaches
Dental Problems: Date of Last Exam ____ / ____ / ____
_________________________________________________________________
Other (please describe): ______________________________
Was the health history reviewed by a health professional?
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Does your child take any medication(s) regularly?
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Yes
Examiner's Initials: _______
No
If yes, list medications:
I understand, due to Health Insurance Portability & Accountability Act HIPAA, that
information regarding my child is confidential. To ensure the best outcome for my child, this
information may be shared with all school personnel.
Yes
No
Reason for medication:
Mother Signature: ________________________________________
Date: ______________
Father Signature: _________________________________________
Date: ______________
INSURANCE STATEMENT
Our son / daughter will comply with the specific insurance regulations of the school.
Family Insurance Co.
Contract #
Group #
SIGNATURE OF PARENT OR GUARDIAN:
MEDICAL TREATMENT CONSENT - To be completed by Parent or Guardian
I, _____________________________________________, the parent or guardian of ______________________________________________, recognize that as a result of
athletic participation, medical treatment on an emergency basis may be necessary, and further recognize that school personnel may be unable to contact me for my consent for
emergency medical care. I do hereby consent in advance to such emergency care, including hospital care, as may be deemed necessary under the then existing circumstances
and to assume the expenses of such care.
SIGNATURE OF PARENT OR GUARDIAN:
DATE
CONSENT - To be completed by Parent or Guardian
I hereby give my consent for the above student to engage in interscholastic athletics and for the disclosure to the MHSAA of information otherwise protected by FERPA and HIPAA
for the purpose of determining eligibility for interscholastic athletics; and I understand the possibility that serious injury may result from participating in athletic activities. He/she has
my permission to accompany the team as a member on its out-of-town trips. I further understand that my son or daughter will be expected to adhere firmly to all established
athletic policies of the school district and the Michigan High School Athletic Association.
SIGNATURE OF PARENT OR GUARDIAN:
DATE
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Parents of children birth to school age shall provide this health appraisal form signed by a licensed physician or his or her designee that a physical evaluation has been made
within the preceding one year. Activity restrictions shall be noted. A current year physical is one given on or after April 15 of the previous school year.
PHYSICAL EXAMINATION, INSPECTION, TESTS AND MEASUREMENTS
Normal
SYSTEM
Under Care
Referred
Normal
SYSTEM
Urinalysis
Heart
Vision
Abdomen
Blood Pressure
Hernia
Hemoglobin/Hematocrit Tested?
Genitalia
Pulse Rate
Neurologic
Ears
Muscular
Nose
Tuberculin Tested
Yes
Type: _________________________
Teeth - Cavities
Neg:
Orthopedic
Pos.:
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_________mm
Yes
Blood Lead Level Tested
Referred
No
Throat
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Under Care
No
Level ________________ µg/dL
Height
Weight
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.
Thyroid
Chest
Lungs
RECOMMENDATIONS
No
Yes
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Is there any defect of vision, hearing or other condition for which the school could help by seating or other actions? If yes, please explain:
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Should the child's activity be restricted because of any physical defect or illness:
If yes, check and explain degree of restriction(s):
Classroom
Playground
Gymnasium
Competitive Sports
Other
IMMUNIZATIONS (Statements such as "UP TO DATE" or "COMPLETE" will not be accepted. Admission to school may be denied on the basis of this information **
VACCINES *
VACCINES
DATE ADMINISTERED
DATE ADMINISTERED
Mo/Day/Yr
Hepatitis B (Hep B)
Mo/Day/Yr
1
Measles, Mumps,
2
Rubella (MMR)
3
Varicella (chickenpox)
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1
2
1
2
DtaP / DTP / DT / Td / Tdap
1
5
(circle type)
2
6
Hepatitis A (Hep A)
1
2
3
7
Influenza (TIV/LAIV)
1
2
4
8
3
4
Chickenpox disease?
Yes
No
If yes, date:
Haemophilus
1
3
Meningococcal (MCV4 / MPSV4
1
2
Influenza type b (HIB)
2
4
Human Papillomavirus
1
3
Polio (IPV / OPV)
1
3
(HPV)
2
(circle type)
2
4
Other Vaccines:
Pneumococcal
1
3
(Specify date & type)
Conjugate (PCV7)
2
4
Rotavirus (RV)
1
3
4
Type
Date:
2
I certify that the immunization dates are true to the best of my knowledge.
Parent/Guardian refused immunizations:
PHYSICIAN'S SIGNATURE
SIGNATURE OF EXAMINER:
DATE
PRINTED NAME OF EXAMINER:
DATE
CIRCLE ONE:
MD
MI
City
Number & Street
DO
PA
NP
(________)
ZIP
Phone
*According to Act 368, Public Acts of 1978, any child enrolling in a Michigan school for the first time must be adequately immunized, vision tested and hearing tested. Exemptions to these requirements are granted for medical, religious, and
other objections provided that waiver forms are properly prepared, signed, and delivered to school administrators. Forms for these exemptions are available at your school or local health department.
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