M.T. Curry Inc - Publicforms

Available Forms

12 Month Wellness Exam 12 Month Wellness Exam Spanish 18 Month Wellness Exam 18 Month Wellness Exam Spanish 24 Month Wellness Exam 24 Month Wellness Exam Spanish 3-21 Year Wellness Exam 3-21 Year Wellness Exam Spanish ACT 12 years and older ACT 12 years and older Spanish ACT 4 to 11 years ACT 4 to 11 years Spanish ADHD Agreement ADHD Agreement Spanish Adult ADHD Self-Report Scale Adult ADHD Self-Report Scale Spanish Conner's Pediatric Conner's Pediatric Spanish COVID-19 Screening English COVID-19 Screening Spanish 2 Family Medical History Family Medical History Spanish Flu Quest 2020 Flu Quest 2020 Spanish HIPAA 18yr HIPAA 18yr Spanish Interview & Lunch Rep COVID-19 Screening New Patient Registration New Patient Registration Spanish Newborn Insurance Waiver Newborn Insurance Waiver Spanish PHQ-9 and GAD (Patient Health Questionnaire and General Anxiety Disorder) PHQ-9 (Patient Health Questionnaire) PHQ-9 (Patient Health Questionnaire) Spanish Records Request Personal Use Records Request Personal Use Spanish Records Request Prior Doctor Records Request Prior Doctor Spanish Self Pay Waiver Self Pay Waiver Spanish Telehealth Agreement Update Demographics Returned Mail Vanderbilt - Parent Well Child Waiver Well Child Waiver Spanish

ACT 4 to 11 years

Patient Name *

First & Last

Date of Birth *

Patient's DOB

Today's Date *

Parent or Guardian: The Childhood Asthma Control Test* is a way to help your child?s healthcare provider determine if your child?s asthma symptoms are well controlled. Childhood Asthma Control Test for children 4 to 11 years Take this test with your child (ages 4 to 11). Share the results with your child?s healthcare provider. Step 1: Have your child answer the first four questions (1 to 4). If your child needs help, you may help, but let your child choose the answer. Step 2: Answer the last three questions (5 to 7) on your own. Don?t let your child?s answers influence yours. There are no right or wrong answers.

Have your child complete these questions.

1. How is your asthma today? *

2. How much of a problem is your asthma when you run, exercise or play sports? *

3. Do you cough because of your asthma? *

4. Do you wake up during the night because of your asthma? *

Please complete the following questions on your own.

5. During the last 4 weeks, how many days did your child have any daytime asthma symptoms? *

6. During the last 4 weeks, how many days did your child wheeze during the day because of asthma? *

7. During the last 4 weeks, how many days did your child wake up during the night because of asthma? *

* Required field