MEDICAL PASSPORT
Michigan Department of Human Services
Child’s Name:
DOB:
Sex:
Case Number:
Address:
Medicaid Recipient ID #:
Caseworker:
Caseworker Telephone
No.:
BIRTH INFORMATION
Prenatal Care:
Yes
No
Unknown
Full Term Pregnancy:
Yes
Type of Delivery:
Natural
Birth Weight:
Gestational Age:
Prenatal exposure to alcohol or other controlled substances
Yes
No
Unknown
Complications or accidents during pregnancy:
Yes
No
Unknown
Complications during birth:
Yes
No
Unknown
Medications taken by mother during pregnancy:
Birth Defects/Other Physical Problems:
MEDICAL HISTORY (Medications-see page 3)
Allergies and/or reactions to medications:
Food and/or dietary problems:
Has child ever been treated for or diagnosed
with1:
Yes
No Asthma or wheezing
Yes
No Pneumonia
Yes
No Lung problems
Yes
No Diabetes
Yes
No Tonsillitis
Yes
No Cystic Fibrosis
Yes
No Sickle Cell Anemia
Yes
No Anemia
Yes
No Broken Bones/Fractures
Yes
No Meningitis
Yes
No Kidney Infection/Disease
Yes
No Urinary Tract Infection
Yes
No Heart Murmur
Yes
No Congenital Heart Defect
Yes
No Recurrent Ear Infections
Yes
No Convulsions/Seizures
Yes
No Paralysis
SWSS Log No.:
Effective
Date
Resolved
Date
Do not select “No” if answer is unknown; leave response unchecked until receipt of confirmed answer.
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Comments
1
1
No
Unknown
Cesarean
If yes, specify:
If yes, specify:
If yes, specify:
MEDICAL PASSPORT
Case Name:
Yes
No Scarlet Fever
Yes
No Rheumatic Fever
Yes
No Recurrent Sinus Infections
Yes
No Multiple Sclerosis
Yes
No Thyroid (hyper/hypo)
Yes
No Sexually Transmitted Disease
Yes
No Hearing Problems
Yes
No Vision Problems
Yes
No Depression/ anxiety
Yes
No ADD/ADHD
Yes
No Has child ever been hospitalized?
Other chronic medical problems:
Accidents, surgeries and hospitalizations prior to entering care:
DEVELOPMENTAL MILESTONES-indicate age in months
Rolled Over:
Sat Unsupported:
Crawled:
Stood Alone:
Spoke First Word:
Spoke 2 to 3 Words Together:
Walked:
Other:
Reported
Inactive
DEVELOPMENTAL/BEHAVIORAL CONCERNS
Date
Date
Yes
No Problems with sleeping or nightmares
Yes
No Speech/language delays
Yes
No Bad temper/ jealousy
Yes
No Bedwetting
Yes
No Threatens or bullies others
Yes
No Physical aggression
Yes
No Poor school attendance
Yes
No Difficulties in getting along with others
Yes
No Breath holding
Yes
No Danger to others
Yes
No Self-Mutilation
Yes
No Other self-harm
Yes
No Encopresis/enuresis
Yes
No Sexual aggression
Yes
No Runaway
Yes
No Cruel to animals
Other developmental or behavioral concerns:
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Toilet Trained:
Fed Self with Utensils:
Dressed Self:
Comments
2
MEDICAL PASSPORT
Case Name:
DENTAL HISTORY
Age at first dental visit:
Has child had any injuries to teeth or jaw?
Dental concerns:
Date of last dental visit:
FAMILY MEDICAL HISTORY-medical conditions of family members of child. Add comments concerning the medical condition and identify the specific relative in Comments field.
Medical Condition
Allergies
Asthma
Bronchitis
Cancer
Cirrhosis of the liver
Congestive heart failure
Diabetes
Emphysema
Epilepsy
Heart attack
Heart disease
Hemophilia
Hepatitis
High blood pressure/hypertension
High cholesterol
Hodgkin’s Disease
Kidney Failure/dialysis/transplant
Multiple Sclerosis
Seizures
Sickle Cell Anemia
Stroke
Thyroid Disease
Tuberculosis
Drug and/or alcohol use
Depression/ anxiety
Other mental health conditions
Other chronic medical conditions
Biological Relative(s)
Comments
CHILD’S INSURANCE INFORMATION
Primary Insurance:
Medicaid Number:
DHS-221 (Rev. 2-13) Previous edition obsolete. MS Word
Group Number:
Medicaid Health Plan:
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MEDICAL PASSPORT
Case Name:
IMMUNIZATION RECORD
VACCINE
Diphtheria Tetanus Pertussis -DTaP
DTaP
DTaP
DTaP
DTaP
Hepatitis B Hep. B
Hep. B
Hep. B
Polio IPV
IPV
IPV
IPV
Haemophilus Influenzae type b -Hib b
Hib b
Hib b
Hib b
Measles Mumps Rubella –MMR
MMR
Varicella
Varicella
PneumococcalPCV
PCV
PCV
PCV
Hepatitis AHep. A
Hep A
RotavirusRV
RV
RV
Human Papillomavirus-HPV
HPV
HPV
MeningococcalMCV4
MCV4
Other:
DOSE
AGE
DATE
Non-Administered
Vaccine
1
2
3
4
5
1
2
3
1
2
3
4
1
2
3
4
1
2
1
2
1
2
3
4
1
2
1
2
3
1
2
3
1
2
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DATE
REASON
MEDICAL PASSPORT
Case Name:
Primary Care Provider Name
Address
City
State
Mental Health Provider Name
Address
City
State
PROVIDER
DATE OF
SERVICE
PENDING/
Completed
APPOINTMENT TYPE2
Phone Number
Zip Code
Phone Number
DIAGNOSIS/OUTCOMES/FINDINGS/RECOMMENDATIONS
2
Include hospitalizations, emergency room and urgent care visits.
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Zip Code
5
MEDICAL PASSPORT
Case Name:
MEDICATION RECORD
Type
Medication
Dosage
Start Date
End Date
Reason for Medication
*Indicate General or Psychotropic medication
A child’s medical records are private and confidential, and can be shared with child care providers and medical providers. Per MCL 333.5131, there are strict rules of confidentiality for persons
diagnosed with HIV infection, acquired immunodeficiency syndrome (AIDS) or other serious communicable diseases. A person who violates this section of law is guilty of a misdemeanor,
punishable by imprisonment for not more than 1 year or a fine of not more than $5,000.00, or both, and is liable in a civil action for actual damages or $1,000.00, whichever is greater, and costs and
reasonable attorney fees.
DHS-221 (Rev. 2-13) Previous edition obsolete. MS Word
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MEDICAL PASSPORT
Case Name:
Medicaid Recipient ID #
DOB:
SIGNATURE PAGE
I acknowledge that I have received a copy of the Medical Passport for the child named above. This is in accordance with the Michigan Department of Human Services policy.
The Medical Passport contains:
A) All medical information required by policy or law to be provided to foster parents.
B) A basic medical history.
C) A record of all immunizations.
D) A record of on-going medications.
E) Other information concerning the child’s physical and mental health.
Each of the child’s placement providers (foster parent/kinship caregiver, etc.) have been provided a copy of the Medical Passport along with:

All known history of abuse or neglect of the child;

All known emotional and psychological problems of the child;

All known behavioral problems of the child; and

The documents that verify the above information.
WORKER SIGNATURE:
Date
PRINT Worker Name
FOSTER CARE PROVIDER
SIGNATURE:*
Date
PRINT Foster Care Provider Name
Date of placement:
MEDICAL PROVIDER SIGNATURE:*
Date
MENTAL HEALTH PROVIDER
SIGNATURE:*
Date
A child’s medical records are private and confidential, and can be shared with child care providers and medical providers. Per MCL 333.5131, there are strict rules of confidentiality for persons
diagnosed with HIV infection, acquired immunodeficiency syndrome (AIDS) or other serious communicable diseases. A person who violates this section of law is guilty of a misdemeanor, punishable by
imprisonment for not more than 1 year or a fine of not more than $5,000.00, or both, and is liable in a civil action for actual damages or $1,000.00, whichever is greater, and costs and reasonable
attorney fees.
Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation,
gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a
DHS office in your area.
*Provider signature is required upon receipt of child’s Medical Passport.
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