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

Complete Packet- 6 Months

6 month Developmental

Child's Full Name: *

Child's Date of Birth *

Do you have an appointment? *

Yes, we already have an appointment scheduled

No, I need Ideal Pediatrics to contact me to schedule and appointment.

Please read each questions carefully and check the box that best describes your child's behavior. Check the box if this behavior is a concern for you.

1. When upset, can your baby calm down within a half hour?

Most of the time

Sometimes

Rarely or never

Check if this is a concern

2. Does your baby smile at you and other family members?

Most of the time

Sometimes

Rarely or never

Check if this is a concern

3. Does your baby like to be picked up and held?

Most of the time

Sometimes

Rarely or never

Check if this is a concern

4. Does your baby stiffen and arch her back with picked up?

Most of the time

Sometimes

Rarely or never

Check if this is a concern

5. When talking to your baby, does he look at you and seem to be listening?

Most of the time

Sometimes

Rarely or never

Check if this is a concern

6. Does your baby let you know when she is hungry or sick?

Most of the time

Sometimes

Rarely or never

Check if this is a concern

7. When awake, does your baby seem to enjoy watching or listening to people?

Most of the time

Sometimes

Rarely or never

Check if this is a concern

8. Is your baby able to calm himself down (for example, by sucking on his hand or a pacifier)?

Most of the time

Sometimes

Rarely or never

Check if this is a concern

9. Does your baby cry for long periods of time?

Most of the time

Sometimes

Rarely or never

Check if this is a concern

10. Is your baby's body relaxed?

Most of the time

Sometimes

Rarely or never

Check if this is a concern

11. Does your baby have trouble sucking from a bottle or breast?

Most of the time

Sometimes

Rarely or never

Check if this is a concern

12. Does it take longer than 30 minuets to feed your baby?

Most of the time

Sometimes

Rarely or never

Check if this is a concern

13. Do you and your baby enjoy mealtimes together (including breast and bottle feeding)?

Most of the time

Sometimes

Rarely or never

Check if this is a concern

14. Does your baby have any eating problems, such as gagging, vomiting, or other?

Most of the time

Sometimes

Rarely or never

Other

Check if this is a concern

If other please explain below

If other please describe here:

15. During the day does your baby stay awake for an hour or longer at one time?

Most of the time

Sometimes

Rarely or never

Check if this is a concern

16. Does your baby have trouble falling asleep at naptime or at night?

Most of the time

Sometimes

Rarely or never

Check if this is a concern

17. Does your baby sleep at least 10 hours in a 24-hour period?

Most of the time

Sometimes

Rarely or never

Check if this is a concern

18. Does your baby get constipated or have diarrhea?

Most of the time

Sometimes

Rarely or never

Check if this is a concern

19. Has anyone expressed concerns about your baby's behavior?

Most of the time

Sometimes

Rarely or never

Check if this is a concern

If you checked "sometimes" or "most of the time" please explain:

20. Do you have concerns about your baby's eating or sleeping behaviors? If so, please explain:

21. Is there anything that worries you about your baby? If so, please explain:

22. What things do you enjoy most about your baby?

Bright Futures- What would you like to talk about today?

We are interested in answering your questions. Please check off the boxes for the topics you would like to discuss the most today.

How Your Family Is Doing

Being a good parent and partner

Where to go when you need help

Finding good child care

Finding and joining playgroups

Your Baby's Development

How your baby learns

How your baby can calm down alone

How to keep your baby safe while sleeping

Bedtime routines

Your baby falling asleep on his own

Your child's weight

Feeding Your Baby

Starting solid food

How to add new foods

How much food your baby should eat

Drinking from a cup

Staying on breast milk or formula

Food allergies

Healthy Teeth

Brushing your baby's teeth

Need for fluoride supplements

Safety

Keeping your home safe with a crawling baby

Car safety seats

Preventing burns, falls, choking, and poisoning

Bathtub and water safety

Questions About Your Baby

Have any of your baby's relatives developed new medical problems since your last visit?

Yes

Unsure

Hearing - Do you have concerns about how your child hears?

Yes

Unsure

Vision - Do you have concerns about how your child sees?

Yes

Unsure

Was your child born in a country at high risk for tuberculosis (countries other than the United States, Canada, Australia, New Zealand, or Western Europe)?

Yes

Unsure

Has your child traveled (had contact with resident populations) for longer than 1 week to a country at high risk for tuberculosis?

Yes

Unsure

Has a family member or contact has tuberculosis or a positive tuberculin skin test?

Yes

Unsure

Are cavities a problem for you or anyone else in your family?

Yes

Unsure

Does your child sleep with a bottle?

Yes

Unsure

Does your child continuously breastfeed through the night?

Yes

Unsure

Does your child have any special health care needs?

Yes

If yes, please describe:

Have there been any major changes in your family lately?

Move

Job change

Separation

Divorce

Death in the family

Any other changes?

Check off each of the tasks that your baby is able to do

Rolls over

Sits briefly, leans forward

Likes to play with you

Babbles and tries to "talk" to you

Likes to look around

Begins name recognition

Smiles at people he knows

Puts things in her mouth

Lead Risk Assessment

Have siblings or playmates with lead poisoning?

Yes

Live in or regularly visit a house or day care built before 1950?

Yes

Reside in or visit a house built before 1978 with chipping paint or remodeling within the last 6 months?

Yes

**Mouth or eat non-food items (pica)?

Yes

Play in bare soil or reside in a lead smelting area?

Yes

Reside with an individual that works with or has hobbies using lead?

Yes

Receive unusual medicines or folk remedies?

Yes

Live in an area of the state at high-risk for leas poisoning? (list published annually)

Yes

Edinbergh- Questions For Mom

Mother's Name

As you are pregnant or have recently had a baby, we would like to know how you are feeling. Please check the answer that comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feel today.

In the Past 7 Days:

I (mom)have felt happy:

Yes, all the time

Yes, most of the time

No, not very often

No, not at all

1. I have been able to laugh and see the funny side of things

As much as I always could

Not quite so much now

Definitely not so much now

Not at all

2. I have looked forward with enjoyment to things

As much as I ever did

Rather less than I used to

Definitely less than I used to

Hardly at all

3. I have blamed myself unnecessarily when things went wrong

Yes, most of the time

Yes, some of the time

Not very often

No, never

4. I have been anxious or worried for no good reason

No, not at all

Hardly ever

Yes, sometimes

Yes, very often

5. I have felt scared or panicky for no very good reason

Yes, quite a lot

Yes, sometimes

No, not much

No, not at all

6. Things have been getting on top of me

Yes, most of the time I haven't been able to cope at all

Yes, sometimes I haven't been coping as well as usual

No, most of the time I have coped quite well

No, I have been coping as well as ever

7. I have been so unhappy that I have had difficulty sleeping

Yes, most of the time

Yes, sometimes

Not very often

No, not at all

8. I have felt sad or miserable

Yes, most of the time

Yes, quite often

Not very often

No, not at all

9. I have been so unhappy that I have been crying

Yes, most of the time

Yes, quite often

Only occasionally

No, never

10. The thought of harming myself has occurred to me

Yes, quite often

Sometimes

Hardly ever

Never

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