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UPDOX - PATIENT PORTAL
12 Month Old Milestones
15 Month Old Milestones
18 Month Old Milestones
2 Month Old Milestones
24 Month Old Milestons
36 Month Old Milestones
4 Month Old Milestones
48 Month Old Mileston
6 Month Old Milestone
60 Month Old Milestones
9 Month Old Milestones
Abnormal Involuntary Movement Scale (AIMS)
Adult ADHD Form
Adult Anxiety scale
Adult depression questionnaire
Depression screening (Child)
KHSAA COVID-19 Return to play
Narrative description of child (parent)
New Patient Information
Pediatric health assessment form - 11 to 14 years
Pediatric health assessment form - 2 to 3 years
Pediatric health assessment form - 4 to 5 years
Pediatric health assessment form - 6 to 10 years
Pediatric health assessment form-15 to 18 years
Pediatric health assessment 15-18 months
Pediatric health assessment 19-23 months
Pediatric health assessment 2-4 months
Pediatric health assessment 5-7 months
Pediatric health assessment 8-14 months
Record Release (from us)
Request of Prior Records
Screen for Child Anxiety Related Disorders (SCARED) (to be filled out by parent/guardian)
Date of Birth:
How did the headaches start and how often do they occur?
When did the headaches first start?
How long have the headaches been present?
Are the headache the same each time or are they different each time
How often do the headaches occur and are they becoming more frequent?
Do you know what causes the headaches (for example, certain situations, foods, or medications usually trigger the headaches)
Does physical activity aggravate the headache pain?
Are there any other symptoms that are associated with the headaches? ( for example, weakness, visual change, loss of consciousness)
Does anyone else in the family have headaches?
What symptoms, if any, occur between headaches?
Where is the pain located?
What does it feel like?
How severe is the headache pain using a scale from 1-10 10 being the worst pain you have felt
Do the headaches appear suddenly without warning or with accompanying symptoms?
What time of day do the headaches usually occur?
Is there an aura (changes in vision, blind spots, or bright lights) before the headaches?
What other symptoms occur with the headaches (weakness, nausea, sensitivity to light or noise, decreased appetite, change in attitude or behavior)
How long do the headaches last?
What relieves the headaches: Rest / Medicine?
Is there any other history in which you want to share?
Name and D.O.B. of Guardian completing form
Electronic Signature of Guarantor/Guardian
* Required field
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