School Physical Form– This is needed for all children entering Kindergarten, 6th grade and 9th grade only. This form is not required for any other grades unless transferring to a new school district or moving in/out of state. Any child in daycare or preschool will need this form completed on an annual basis as well.
Sports Physical Form– This form is required every school year for all grades in which your child will be participating in school sports.
Anxiety (SCARED form) and Depression (PHQ9 form) Screenings– These forms are required for each Medication Re-check appointment. These appointments are generally every 3 months unless there has been a change and sooner monitoring is needed.
ADD/ADHD reassessments and Vanderdilt Screenings– These forms are required for each Medication Re-check appointment. These appointments are generally every 3 months unless there has been a change and sooner monitoring is needed.
Boy Scouts, Girl Scouts, Summer Camp forms etc.– You will need to provide these forms to the clinical staff when you present for your child’s wellness exam.
ALL forms must have the child’s portion completed prior to their wellness visit. Any incomplete forms will delay the Physicians and Nurse Practitioners from completing their required sections.
***Please note: A $10 fee may apply for any forms not completed at the time of visit***
Click on a form name below to open the document as a PDF.
New Patient Registration Packet
Patient Information Sheet
Immunization Coverage Questionaire
Medical History Form
Medical Records Request form
Medical records request (Spanish)
authorization to release healthcare information- 18yo and older
School Physical Form
IHSA Pre-participation Exam Form- Sport Physical Form
Vanderbilt Assessment Parent- Initial
Vanderbilt Assessment- Parent followup
Vanderbilt Assessment- Teacher
Vanderbilt Assessment- Teacher followup
Vanderbilt Assessment- Parent Initial Spanish
Vanderbilt Assessment- ParentFollowupSpanish
SCARED- anxiety form- Parent
SCARED- anxiety- child
PHQ9- Depression form
ADHD Reassessment Questionanaire