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 Follow Up

ADHD Follow-up Assesment - PARENT

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. Please think about your child's behaviors since the last assessment scale was filled out when rating his/her behaviors.

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

Performance

19. Overall school performance

Excellent 1

Above Average 2

Average 3

Somewhat of a Problem 4

Problematic 5

20. Reading

Excellent 1

Above Average 2

Average 3

Somewhat of a Problem 4

Problematic 5

21. Writing

Excellent 1

Above Average 2

Average 3

Somewhat of a Problem 4

Problematic 5

22. Mathematics

Excellent 1

Above Average 2

Average 3

Somewhat of a Problem 4

Problematic 5

23. Relationship with parents

Excellent 1

Above Average 2

Average 3

Somewhat of a Problem 4

Problematic 5

24. Relationship with siblings

Excellent 1

Above Average 2

Average 3

Somewhat of a Problem 4

Problematic 5

25. Relationship with peers

Excellent 1

Above Average 2

Average 3

Somewhat of a Problem 4

Problematic 5

26. Participation in organized activities (eg, teams)

Excellent 1

Above Average 2

Average 3

Somewhat of a Problem 4

Problematic 5

Side effects

Has your child experienced any of the following side effects or problems in the past week? Are these side effects currently a problem?

Headache

None

Mild

Moderate

Severe

Stomachache

None

Mild

Moderate

Severe

Change of appetite - explain below

None

Mild

Moderate

Severe

Trouble sleeping

None

Mild

Moderate

Severe

Irritability in the late morning, late afternoon, or evening - explain below

None

Mild

Moderate

Severe

Socially withdrawn - decreased interaction with others

None

Mild

Moderate

Severe

Extreme sadness or unusual crying

None

Mild

Moderate

Severe

Dull, tired, listless behavior

None

Mild

Moderate

Severe

Tremors/feeling shaky

None

Mild

Moderate

Severe

Repetitive movements, tics, jerking, twitching, eye blinking - explain below

None

Mild

Moderate

Severe

Picking at skin or fingers, nail biting, lip or cheek chewing - explain below

None

Mild

Moderate

Severe

Sees or hears things that aren't there

None

Mild

Moderate

Severe

Explain/comments:

For Office Use Only

Total Symptom Score for questions 1-18:

Average Performance Score for questions 19-26:

* Required field