Health Appraisal Form Instructions

Please download the Health Appraisal Form below and have your child’s healthcare provider complete it.

The form must be signed and dated within the past 13 months and include a current immunization record.

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.