Forms

Developmental Assessment

• ADHD Screening Tools
• Autism Screening Tool
• Depression Screen

Health History

• Adolescent Health History Questionnaire
• Headache Diary
• Health Form - 18 years and over
• Health History Questionaire
• Past Medical History Form
• Tuberculosis Risk Assessment

Office Forms

• Acknowledgment of Receipt of Notice of Privacy Practices
• Authorization for Disclosure of Private Health Records
• Criteria for “Life Threatening Illness” for gas/electric companies
• Insurance and Payment Policy
• Patient Information Form

School, Daycare, and Camp Forms

• Authorization for EpiPen / Benadryl Administration
• Authorization for the Administration of Medication by School, Child Care and Youth Camp Personnel
• Early Childhood Health Assessment Record
• Health Assessment Record (Blue Form)
• Youth Camp Health Exam/Record