Here are some PDF files or Word documents containing the forms that the parent or guardian of a new patient will be asked to complete upon establishing themselves as a patient at Right from the Start Pediatrics.
You will be asked to complete these prior to your first appointment, so using these links will save a great amount of time.
The policies to be acknowledged can be found by clicking the Office Policies button to the left.
We thank you in advance for your help!
Health History Form - *now "fill-able" this PDF file requires Adobe Acrobat 9.0 or higher- free download here. You may fill in this form on your computer, then print it and bring it in. Or you may print it and fill it in by hand. We do require a hand written signature on the bottom.
These are some forms that we ask you to complete at different well child visits.
Completing these forms adds a lot of information about a child's mother and the growth and development of the child as time passes. Some of these are from the "Addressing Mental Health Concerns in Primary Care" CD that I purchased from the American Academy of Pediatrics and I would like to give the Academy credit here for providing this valuable resource to me.
Edinburgh Postpartum Depression questionnaire- We ask each new mother to complete this questionnaire at each well child visit until their child is one year old. Research has shown that asking mothers about anxiety and depression several times through the first year can better identify mothers who are suffering from or at risk for postpartum anxiety or depression. The pediatrician can work closely with a mother and her obstetrician to help manage these problems should they arise, and the best way to identify them is by asking. Click the following link for a fill-able version of this questionnaire (password protected - need to be established patient to obtain password):
Edinburgh Postpartum Depression scale (disregard the second page - it is a scoring sheet for office use only - thanks!)
Ages and Stages Questionnaires (ASQ) - developmental questionnaires that I provide to parents to complete prior to several critical well child visits. These ages here are provided to all patients, but other ages can be completed if there are any questions at other ages. Click the following links for fill-able versions of the ASQ (password protected - need to be established patient to obtain password):