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 Español: es 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 Form: This 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.
• Healthy Weight and Assessment:  This form is to be completed by anyone coming in for a Healthy Habits visit.
• ADHD Side Effects: This 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 Español: Este 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 Scale: This 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 Español: Este 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 Listing: List of dentist in the area with phone numbers and insurance carriers.
• Psychological List: List of Psychologists/psychiatrists  in the area with phone numbers and insurance carriers.
• Release of Information FROM Haywood Pediatrics: This form is used to release information from our practice to someone or somewhere else. Please remember only the parent or legal guardian may sign for records to be released.
• Release of Information TO Haywood Pediatrics: This 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.