Health Appraisal Form Instructions

Please contact your child’s healthcare provider for a copy of your child’s Health Appraisal.

The form must be signed and dated within 13 months of start date and include a current immunization record.

When submitting your pages, please use the scan function on your phone to combine all pages into a single PDF.

To ensure your child’s Health Appraisal meets state requirements, please review the following before submitting:

• Section 1 – Personal Information
  Completed by the parent/guardian.

• Section 3 – Physical Examination, Inspection, Tests, and Measurements
  Please ensure the exam date is completed at the end of this section.

• Section 4 – Immunizations
  Immunizations should be recorded on the form or an up-to-date immunization record must be attached.
  Please notify us if your child has an immunization waiver from the Health Department.

• Section 5 – Recommendations
  Must include the healthcare provider’s signature.

• Section 7 – Physician’s Signature
  This section must be fully completed with a provider signature or official office stamp.

Thank you for taking the time to carefully review this form. Having complete and accurate information helps us meet the requirements set by the State of Michigan Child Care Licensing and ensures the best care for your child.