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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 Bed wetting Child ADD/ADHD Demo Adult Demo Child Depression screening (Child) Headache Intake KHSAA COVID-19 Return to play Narrative description of child (parent) New Patient Information 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 Pediatric Symptom Checklist Youth 12-17 Pediatric Symptom Checklist Youth 6-11 PHQ- 9: Modified for Teens Record Release (from us) Request of Prior Records Screen for Child Anxiety Related Disorders (SCARED) (to be filled out by parent/guardian) Suicide Risk Screen ASQ tool

Pediatric Symptom Checklist Youth 6-11

Please choose the best answer for each symptom

1. Complains of aches or pains *

2. Spends more time alone *

3. Tires easily, little energy *

4. Fidgety, unable to sit still *

5. Has trouble with teachers *

6. Less interested in school *

7. Acts as if driven by a motor *

8. Daydreams too much *

9. Distracted easily *

10. Is afraid of new situations *

11. Feels sad, unhappy

12. Is irritable, angry *

13. Feels hopeless *

14. Has trouble with concentration *

15. Less interested un friends *

16. Fights with other children *

17. Absent from school *

18. School grades dropping *

19. Down on yourself *

20. Visits doctor with doctor finding nothing wrong *

21. Has trouble sleeping *

22. Worries a lot *

23. Wants to be with parent more than before *

24. Feels that they are bad. *

25. Takes unnecessary risks *

26. Gets hurt frequently *

27. Seems to be having less fun *

28. Acts younger than other children their age *

29. Does not listen to rules *

30. Does not show feelings *

31. Does not understand other people's feelings *

32. Teases others *

33. Blames others for your troubles *

34. Takes things that do not belong to them *

Refuses to share *

* Required field