Forms
Patient Forms
PLEASE READ THIS BEFORE GOING ANY FURTHER!
Developmental Screenings are to be done for children from 2 months to 36 months of age. It is helpful if you can complete the questionnaire within 1-2 days of your child's scheduled appointment. Please advise the receptionist at check-in that you completed the screening online. Please complete this for all 2 month through 3 year old well child visits.
Patient Forms
When you complete our registration form you may notice that we have added areas asking about race, ethnicity and religion. Data collection is useful in the healthcare industry to ensure that reliable and information rich data is collected for use in statistical analysis. For Example, this allows researchers to pin-point certain information and make decisions from that information. This can help encourage preventative health care and testing to certain groups that may be more at risk.
CHSAA-Sports-Evaluation-Forms PDF
Ages 11 and up, complete the first 2 pages of the CHSAA form and bring all pages with you to your Well Visit appointment.
All patients 11 years old and above and do not need a CHSSA form, please complete this form prior to your well child appointment.
Please print and complete.
Please print and complete.
Please print, complete form and bring to your Concussion appointment.
Social-Determinants-of-Health-Questionnaire PDF
Social Determinants of Health are conditions in the environments in which people are born, live, learn, work, play and worship. A combination of these factors with age affect a wide range of health, functioning and quality-of-life outcomes and risks (Healthy People 2020). It is estimated that 60-85% of health outcomes are influenced by health behaviors and socio-economic factors (State of Colorado). Addressing whole-person health can increase the value of the health care provided and impro...
Asthma
Parents Asthma form
Asthma Form for 4 years through 11 years
Asthma Form for 12 years old and up
Behavior
Please print and complete this form and bring to your child's 18 month and 24 month well child visits.
NICHQ_Vanderbilt_Assessment_Scales PDF
Parent and Teacher Forms. Please bring the completed forms with you to your child's appointment.
Developmental Pediatric Clinic ASD Focused Health/Developmental History/ Ages 0-5
Developmental Pediatric Clinic ASD Focused Health/Developmental History/ Ages 6+
Mental Health
Patient to complete prior to appointment.
SCARED-form-Parent-and-Child-version PDF
Child to complete the first 2 pages. Parent to complete the remaining pages.
We hope this list is help be helpful in your search for a mental health provider. Always check with your insurance also!
Vaccine Consent Forms
Screening-Form-for-Immunization PDF
INFLUENZA and/or COVID Vaccine Consent Form 2024-2025
Screening-Form-for-Immunization-xlsx PDF
Screening form for routine vaccine. This is NOT for the flu or covid vaccines
Printable Office Forms
Prior to your appointment, the forms listed below can be printed for your convenience. Filling them out beforehand will save you time by not having to complete them during your appointment. If you elect not to fill out these forms ahead of time, please arrive 15 minutes prior to your scheduled time. (You may download Adobe Reader for free at www.adobe.com.)
Release of Information
In order for us to receive your child's previous medical records, you will need to complete this form and send it to the previous provider. The previous provider may charge for this. In this case the cost will be your responisbility.
Registration Form 2024
An registration form is required for new patients and is updated annually.
Family Health History
New Patients are asked to complete our Family history form. This helps us know your child better!
Well Check Forms
- MCHAT - 18 month and 2 year old visit PDF
- Edinburgh Postnatal Depression Scale For Moms with infants 2 weeks through 6 mos, please complete at their well visits. PDF
- SCARED Anxiety Screen (child to complete) Complete if having anxiety concerns PDF
- PHQ-9 (Modified for Teens) Complete at all well visits ages 12 and up. PDF
- CHSAA Sports Evaluation. PDF Complete prior to well visits for 11 year olds and up.
Asthma Assessment Forms
Parents and patients are asked to complete these forms for asthma rechecks.
Behavioral Health Forms
Vaccine Consent Forms
A consent form accompanies the patient when coming in for an immunization only visit.
New Patient Conference Schedule
If you are looking for a Pediatrician for your child, we invite you to attend one of our New Patient Conferences. Please see the link below and call to schedule.
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