Illini Pediatrics LLC, DBA Ideal Pediatrics

Available Forms

2020 - Covid Policy Addendum 2020- Established PT Update 2020- Health History 2020- New Patient Intake 2020- Office Policy/CCOF ACT--Asthma control Test (12yr+) ACT--Asthma control Test (4-11yr) ADHD Parent Follow Up ADHD Parent Initial Behavioral intake (for ages 8 and older) Behavioral intake (up to 7 years old) Complete Packet- 0-5 day (newborn) Complete Packet- 1 month Complete Packet- 10 year Complete packet- 11-14 yr (parent) Complete Packet- 12 months Complete Packet- 15 months Complete packet- 15-17year (parent) Complete Packet- 18 months Complete Packet- 2 month Complete Packet- 24 months Complete Packet- 3 year Complete Packet- 4 month Complete Packet- 4 Year Complete Packet- 5 yr Complete Packet- 6 Months Complete Packet- 6 yr Complete Packet- 7 yr Complete Packet- 8 Year Complete Packet- 8 Year Complete Packet- 9 Months Complete Packet- 9 year Complete Packet- Older Adolescent Packet 15-18 (child) Complete Packet- Younger Adolescent 11-14 (Child) Complete Packet-30 month Covid consent COVID Test- Non Patient Covid Vaccine Registration GAPS 11-14yr GAPS 15-18yr Generalized Anxiety Disorder 7-Item Scale PHQ9 Prevaccination Checklist for COVID-19 Vaccines RAPID TEST ONLY- Patient Intake Release of records TO IDEAL PEDIATRICS SCARED Vaccine Declination Vaccine FLU Contraindications Vaccine Screening for Contraindication Vaccine VFC Eligibility Screening

ADHD Parent Initial

ADHD Initial Assessment - Parent form

Today's Date: *

Child's Name: *

Date of Birth: *

Parent's Name: *

Parent's Phone Number:

Directions: Each rating should be considered in the context of what is appropriate for the age of your child. When completing this form, please think about your child's behaviors in the past 6 months.

Is this evaluation based on a time when the child *

was on medication

was not on medication

not sure?

Symptoms

1. Does not pay attention to details or makes careless mistakes with, for example, homework

Never 0

Occasionally 1

Often 2

Very Often 3

2. Has difficulty keeping attention to what needs to be done

Never 0

Occasionally 1

Often 2

Very Often 3

3. Does not seem to listen when spoken to directly

Never 0

Occasionally 1

Often 2

Very Often 3

4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)

Never 0

Occasionally 1

Often 2

Very Often 3

5. Has difficulty organizing tasks and activities

Never 0

Occasionally 1

Often 2

Very Often 3

6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort

Never 0

Occasionally 1

Often 2

Very Often 3

7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books)

Never 0

Occasionally 1

Often 2

Very Often 3

8. Is easily distracted by noises or other stimuli

Never 0

Occasionally 1

Often 2

Very Often 3

9. Is forgetful in daily activities

Never 0

Occasionally 1

Often 2

Very Often 3

10. Fidgets with hands or feet or squirms in seat

Never 0

Occasionally 1

Often 2

Very Often 3

11. Leaves seat when remaining seated is expected

Never 0

Occasionally 1

Often 2

Very Often 3

12. Runs about or climbs too much when remaining seated is expected

Never 0

Occasionally 1

Often 2

Very Often 3

13. Has difficulty playing or beginning quiet play activities

Never 0

Occasionally 1

Often 2

Very Often 3

14. Is "on the go" or often acts as if "driven by a motor"

Never 0

Occasionally 1

Often 2

Very Often 3

15. Talks too much

Never 0

Occasionally 1

Often 2

Very Often 3

16. Blurts out answers before questions have been completed

Never 0

Occasionally 1

Often 2

Very Often 3

17. Has difficulty waiting his or her turn

Never 0

Occasionally 1

Often 2

Very Often 3

18. Interrupts or intrudes in on others' conversations and/or activities

Never 0

Occasionally 1

Often 2

Very Often 3

19. Argues with adults

Never 0

Occasionally 1

Often 2

Very Often 3

20. Loses temper

Never 0

Occasionally 1

Often 2

Very Often 3

21. Actively defies or refuses to go along with adults' requests or rules

Never 0

Occasionally 1

Often 2

Very Often 3

22. Deliberately annoys people

Never 0

Occasionally 1

Often 2

Very Often 3

23. Blames others for his or her mistakes or misbehaviors

Never 0

Occasionally 1

Often 2

Very Often 3

24. Is touchy or easily annoyed by others

Never 0

Occasionally 1

Often 2

Very Often 3

25. Is angry or resentful

Never 0

Occasionally 1

Often 2

Very Often 3

26. Is spiteful and wants to get even

Never 0

Occasionally 1

Often 2

Very Often 3

27. Bullies, threatens, or intimidates others

Never 0

Occasionally 1

Often 2

Very Often 3

28. Starts physical fights

Never 0

Occasionally 1

Often 2

Very Often 3

29. Lies to get out of trouble or to avoid obligations (ie, "cons" others)

Never 0

Occasionally 1

Often 2

Very Often 3

30. Is truant from school (skips school) without permission

Never 0

Occasionally 1

Often 2

Very Often 3

31. Is physically cruel to people

Never 0

Occasionally 1

Often 2

Very Often 3

32. Has stolen things that have value

Never 0

Occasionally 1

Often 2

Very Often 3

33. Deliberately destroys others' property

Never 0

Occasionally 1

Often 2

Very Often 3

34. Has used a weapon that can cause serious harm (bat, knife, brick, gun)

Never 0

Occasionally 1

Often 2

Very Often 3

35. Is physically cruel to animals

Never 0

Occasionally 1

Often 2

Very Often 3

36. Has deliberately set fires to cause damage

Never 0

Occasionally 1

Often 2

Very Often 3

37. Has broken into someone else's home, business, or car

Never 0

Occasionally 1

Often 2

Very Often 3

38. Has stayed out at night without permission

Never 0

Occasionally 1

Often 2

Very Often 3

39. Has run away from home overnight

Never 0

Occasionally 1

Often 2

Very Often 3

40. Has forced someone into sexual activity

Never 0

Occasionally 1

Often 2

Very Often 3

41. Is fearful, anxious, or worried

Never 0

Occasionally 1

Often 2

Very Often 3

42. Is afraid to try new things for fear of making mistakes

Never 0

Occasionally 1

Often 2

Very Often 3

43. Feels worthless or inferior

Never 0

Occasionally 1

Often 2

Very Often 3

44. Blames self for problems, feels guilty

Never 0

Occasionally 1

Often 2

Very Often 3

45. Feels lonely, unwanted, or unloved; complains that "no one loves him or her"

Never 0

Occasionally 1

Often 2

Very Often 3

46. Is sad, unahppy, or depressed

Never 0

Occasionally 1

Often 2

Very Often 3

47. Is self-conscious or easily embarrassed

Never 0

Occasionally 1

Often 2

Very Often 3

Performance

48. Overall school performance

Excellent 1

Above Average 2

Average 3

Somewhat of a Problem 4

Problematic 5

49. Reading

Excellent 1

Above Average 2

Average 3

Somewhat of a Problem 4

Problematic 5

50. Writing

Excellent 1

Above Average 2

Average 3

Somewhat of a Problem 4

Problematic 5

51. Mathematics

Excellent 1

Above Average 2

Average 3

Somewhat of a Problem 4

Problematic 5

52. Relationship with parents

Excellent 1

Above Average 2

Average 3

Somewhat of a Problem 4

Problematic 5

53. Relationship with siblings

Excellent 1

Above Average 2

Average 3

Somewhat of a Problem 4

Problematic 5

54. Relationship with peers

Excellent 1

Above Average 2

Average 3

Somewhat of a Problem 4

Problematic 5

55. Participation in organized activities (eg, teams)

Excellent 1

Above Average 2

Average 3

Somewhat of a Problem 4

Problematic 5

Comments:

For Office Use Only

Total number of questions scored 2 or 3 in questions 1-9:

Total number of questions scored 2 or 3 in questions 10-18:

Total Symptom Score for questions 1-18:

Total number of questions scored 2 or 3 in questions 19-26:

Total number of questions scored 2 or 3 in questions 27-40:

Total number of questions scored 2 or 3 in questions 41-47:

Total number of questions scored 4 or 5 in questions 48-55:

Average Performance Score:

* Required field