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

PHQ9

Patient Last Name *

Patient First Name

Child's Date of Birth

Todays' date

Patient Health Questionnaire (PHQ-9)

Over the last 2 weeks, how often have you been bothered by any of the following problems? 0- Not at all 1- Several Days 2- More than half the days 3-Nearly Every Day

1. Little interest or pleasure in doing things

2. Feeling down, depressed, or hopless

3. Trouble falling or staying asleep, or sleeping too much.

4. Feeling tired or having little energy

5. Poor appetite or overeating

6. Feeling bad about yourself or that you are a failure, or have let yourself or your family down

7. Trouble concentraiting on things, such as reading the newspaper or watching television

8. Moving or speaking so slowly that other people could have noticed. Or the opposite, being so figety or restless that you have been moving around more than usual

9.Thoughts that you would be better off dead or of hurting yourself

10. If you checked off any of the above problems, how difficult have these problems made it fo ryou to do your work, take care of things at home, or get along with other people?

* Required field