Patient Information

At Haywood Pediatrics, our goal is to provide you with relevant and trustworthy information. This section contains forms that make up what you will need for visits. You can print these forms, complete them at home and bring them into the office at the time of your child's visit.

PATIENT UPDATES

  • New Patient Demographics: This form is filled out by all new patients (with the exception of  foster parents, see below for those) and gives us information such as address and phone number.
  • New Patient Demographics- En Español: Este formulario es llenado por todos los nuevos pacientes (excepto para los padres adoptivos, ver más abajo para éstos) y proporciona información como la dirección y número de teléfono.
  • Patient Information Update: This form is filled out yearly to update HIPAA and address and phone numbers. Up to 4 children may be listed on this form. This form is used with the exception of 18 year old and older and foster parents, see below for those.
  • Patient Information Update- En Español: Este formulario es llenado anualmente para actualizar HIPAA, dirección y números de teléfono. Hasta 4 niños pueden estar señalados en este formulario. Este formulario se utiliza con la excepción de los pacientes18 años de edad y mayores y los padres de crianza, ver más abajo para esos.
  • 18 Year+ Update: This form is to be completed by the patient themselves  for any patient that is 18 years or older when they turn 18 and every year thereafter.
  • Foster Parent Form: This form is to be completed by those that have temporary custody of a child (such as foster care, Broyhill Children’s Home, kinship, etc…) and every year thereafter for as long as they have temporary custody.

FORMS TO BE COMPLETED FOR VISITS

  • ADHD Forms: These forms will need to be picked up at one of our 2 locations to be completed. Please bring these forms to the initial evaluation and all follow-ups.
  • MCHAT: The Modified Checklist for Autism in Toddlers (M-Chat) is a validated developmental screening tool for toddlers between 18 and 36 months of age. It is designed to identify children who may benefit from a more thorough developmental and autism evaluation. Please print this off, complete it and bring it with you to your well child visit.
  • MCHAT- En Españoles una herramienta de evaluación del desarrollo validado para los niños de entre 18 y 36 meses de edad. Está diseñado para identificar a los niños que pueden beneficiarse de una evaluación más completa del desarrollo y autismo. Por favor imprima esta apagado, completarlo y llevarlo con usted a su visita del niño sano.
  • Asthma Evaluation FormThis form is to be completed by anyone coming in for an Asthma Evaluation or follow-up if you have not already completed one. Please print this off, complete it and bring it with you to your visit.
  • Asthma Evaluation Form- En Español: Este formulario debe ser completado por cualquier persona que entra para una evaluación del asma o de seguimiento, si aún no lo ha terminado uno. Por favor imprima esta apagado, completarlo y llevarlo con usted a su visita.
  • Childhood Asthma Control Test:This form is to be completed by anyone coming in for an Asthma Evaluation or follow-up. Please print this off, complete it and bring it with you to your visit.
  • Childhood Asthma Control Test - En Español: Este formulario debe ser completado por cualquier persona que viene adentro para una Evaluación del Asma o seguimiento. Por favor imprima esta apagado, completarlo y llevarlo con usted a su visita.
  • Asthma Self Management Form: This form is to be completed by anyone coming in for an Asthma  follow-up. Please print this off, complete it and bring it with you to your visit.
  • ADHD Side EffectsThis form is to be completed by anyone coming in for an ADHD follow-up. Please print this off, complete it and bring it with you to your visit.
  • ADHD Side Effects- En EspañolEste formulario debe ser completado por cualquier persona que viene adentro para un TDAH seguimiento. Por favor imprima esta apagado, completarlo y llevarlo con usted a su visita.
  • Edinburgh Depression ScaleThis questionnaire screens for depression in mothers of young babies it is to be completed by the moms at the babies 2 and 4 month visits. Please print this off, complete it and bring it with you to your visit.
  • Edinburgh Depression Scale- En EspañolEste cuestionario pantallas para la depresión en las madres de los bebés es para ser completado por las madres en los bebés 2 y 4 visitas mensuales. Por favor imprima esta apagado, completarlo y llevarlo con usted a su visita.
  • Pediatric Symptom Checklist (6-10 years)This screen is used to assess the behavioral and emotional well being of your child. It is completed by the parent/guardian at ages 6-10 years at the well child visits. Please print this off, complete it and bring it with you to your well child visit.
  • Pediatric Symptom Checklist-En Español (6-10 años)Esta pantalla se utiliza para evaluar el comportamiento y el bienestar emocional de su hijo. Se completa con los padres / tutores en las edades de 6-10 años en las visitas de rutina. Por favor imprima esta apagado, completarlo y llevarlo con usted a su visita del niño sano.
  • Youth-Pediatric Symptom Checklist (11-16 years)This screen is used to assess the behavioral and emotional well being of your adolescent. It is completed by the child at ages 11-16 years at the well child visits. Please print this off, complete it and bring it with you to your well child visit.
  • Youth-Pediatric Symptom Checklist-En Español (11-16 años)Esta pantalla se utiliza para evaluar el bienestar conductual y emocional de su hijo adolescente. Se completa con el niño en las edades de 11-16 años en las visitas de rutina. Por favor imprima esta apagado, completarlo y llevarlo con usted a su visita del niño sano.

GENERAL INFORMATION:

  • Notice of Privacy Practices:  This notice describes how medical information about our patients may be used and disclosed and how you may obtain access to this information. PLEASE READ IT CAREFULLY.
  • Consent To Treat Children (Other than Parent)The purpose of these forms is to give permission for someone other than the parent or legal guardian to consent to medical care for a certain child. For example, if a parent/legal guardian is going out of town or is otherwise unavailable this notarized document can be included in the child's record. We do have a notary within our practice that can notarize office specific forms.
  • Dentist ListingList of dentist in the area with phone numbers and insurance carriers.
  • Psychological ListList of Psychologists/psychiatrists  in the area with phone numbers and insurance carriers.
  • Release of Information TO Haywood PediatricsThis form is used to release information to our practice from someone or somewhere else. Please remember only the parent or legal guardian may sign for records to be released.