Forms to download

Demographics – under 18 (English) (Spanish)
Demographics- 18 and older
HIPPA- Privacy Practices Notice (English and Spanish)
Patient’s Medical Surgical History Questionnaire (English and Spanish)
Pre-participation History and Physical Examination Questionnaire
Release of information (English & Spanish)

Authorization for Medication at School
Demographics – under 18  (English) (Spanish)
Demographics – 18 and older
HIPPA- Privacy Practices Notice (English and Spanish)
Patient’s Medical Surgical History Questionnaire (English and Spanish)
Release of information (English & Spanish)

ADHD

Authorization to Exchange of information pertaining to ADHD (English and Spanish)
NIHCQ Parent Assessment (Initial)
NIHCQ Parent Assessment Follow Up (Spanish)
NIHCQ Teacher Assessment Scale (Initial)
NICHQ Teacher Follow-Up (Informant)

Depression

PHQ-A (English) (Spanish)
SMFQ (4 – 10, to be completed by parent)

Anxiety

GAD-7 (11 and older, to be completed by patient)
PSC-17 (Pediatric Symptom Checklist)
Screen for Child Anxiety Related Disorder (SCARED) – to be completed by parent
Screen for Child Anxiety Related Disorder (SCARED) – to be completed by child

General

PSC-17 (Pediatric Symptom Checklist)

ACT (Asthma Control Test) 4-11 years (English) (Spanish)
ACT (Asthma Control Test) 12 and older (English) (Spanish)

Ages and Stages Questionnaire (ASQ) – 8 months
Ages and Stages Questionnaire (ASQ) – 9 months
Ages and Stages Questionnaire (ASQ) – 10 months
Ages and Stages Questionnaire (ASQ) – 18 months
Ages and Stages Questionnaire (ASQ) – 24 months
Ages and Stages Questionnaire (ASQ) – 30 months