Please print and complete applicable forms prior to your child’s visit. When you check-in, please let front staff know you have already completed the forms and brought them with you to the visit.
For New Patients
OTP New Patient forms and NPP
Nuevos Formularios Para Pacientes
Notificacion de practicas de privacidad
Medical History Information Sheet
For Existing Patients
Well Visit Forms:
Edinburgh Postnatal Depression Scale English
Escala Edinburgh para la depression postnatal (Spanish Version)
( To be completed at newborn visit, 1-2 week check, 1 month well check )
Pediatric Symptom Checklist (PSC)
Lista de sintomas pediatricos (PSC Spanish)
(To be completed by parent’s for well check visits for patients age 6-11 years)
Pediatric Symptom Checklist-Youth Report (Y-PSC)
Lista de Sintomas de pediatria- informe del joven (Y-PSC)
(To be completed by adolescent for well check visits ages 12-18 years)
M-CHAT-R SPANISH
( To be completed at 18 month well check and 24 month well check )
Attention Deficit and Hyperactivity Disorder (ADHD) Forms
D-3 Vanderbilt ADHD form parent English
D-3 Sistema Vanderbilt ADHD para padres Spanish
D-4 Vanderbilt ADHD from teacher English
Behavior Rating Scales (ouhsc.edu)
Asthma Forms:
Childhood Asthma Control Test for children 4-11 years English
Asthma Control Test for people 12 yrs and older (getasthmahelp.org)
Prueba de control del asma de la infancia para ninos
(To be completed at each asthma follow-up appointment and well check in patients with asthma)
https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent-shell.html
Depression and Anxiety formshttps://www.ohsu.edu/sites/default/files/2019-06/SCARED-form-Parent-and-Child-version.pdf