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

Vanderbilt - Parent

Patient Name *

First & Last

Date of Birth *

Patient DOB

Parent Name *

First & Last

Phone Number *

Today's Date *

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 *

SYMPTOMS

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

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

3. Does not seem to listen when spoken to directly *

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

5. Has difficulty organizing tasks and activities *

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

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

8. Is easily distracted by noises or other stimuli *

9. Is forgetful in daily activities *

10. Fidgets with hands or feet or squirms in seat *

11. Leaves seat when remaining seated is expected *

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

13. Has difficulty playing or beginning quiet play activities *

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

15. Talks too much *

16. Blurts out answers before questions have been completed *

17. Has difficulty waiting his or her turn *

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

19. Argues with adults *

20. Loses temper *

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

22. Deliberately annoys people *

23. Blames others for his or her mistakes or misbehaviors *

24. Is touchy or easily annoyed by others *

25. Is angry or resentful *

26. Is spiteful and wants to get even *

27. Bullies, threatens, or intimidates others *

28. Starts physical fights *

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

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

31. Is physically cruel to people *

32. Has stolen things that have value *

33. Deliberately destroys others? property *

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

35. Is physically cruel to animals *

36. Has deliberately set fires to cause damage *

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

38. Has stayed out at night without permission *

39. Has run away from home overnight *

40. Has forced someone into sexual activity *

41. Is fearful, anxious, or worried *

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

43. Feels worthless or inferior *

44. Blames self for problems, feels guilty *

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

46. Is sad, unhappy, or depressed *

47. Is self-conscious or easily embarrassed *

PERFORMANCE

48. Overall school performance *

49. Reading *

50. Writing *

51. Mathematics *

52. Relationship with parents *

53. Relationship with siblings *

54. Relationship with peers *

55. Participation in organized activities (eg, teams) *

Comments

For Office Use

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