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Please note: The Parent / Patient Handouts are on the Handout Page in the Information Section

 

CYS Forms:

Special Diet Statement

Allergy Action Plan

Respiratory Action Plan

Seizure Action Plan

Diabetes Action Plan

Permission to Give Medication in school or daycare

Permission to Give Asthma Medication in school or daycare

Sport Participation Examination  (not an H&P form, just confirmation of examination)

Camp Participation Exam  (not an H&P form, just confirmation of examination)

Excuse from Physical Education

School Excuse (to return after illness)

Visit Documentation (for parent's absence from work)

WIC Rx Form 2009

Circumcision Permit

Home Nebulizer Authorization Paperwork (attach a printout of meds prescribed to this completed form)

Adverse Drug Reaction (ADR) Report - Online Form

Incident Report - e-4106 - Online Form

EFMP Enrollment Form (DD 2792)

EFMP Educational Enrollment (DD 2791-2

Special Drug Request form for Daytrana Patch or Focalin

Synagis Screening Questionnaire)

M-CHAT (Modified Checklist for Autism in Toddlers)

M-CHAT Scoring Directions

M-CHAT Scoring the Easy Way

Disabled Parking Form

BMI Calculator

Supplemental Newborn Screening Information

Fax Cover Sheet

Metabolic Letter

Immunization Refusal Form

Child Find Request Form

 

Blank Clinic Banner Letterhead

 


 

ADHD Forms

These packets are best suited to printing "2 sided, Flip on Long Edge"

 

School Packet - cover letter plus 2 NICHQ Vanderbilt Teacher Assessment Scales (initial)

Parent Packet - 12-page developmental history form plus 2 NICHQ Vanderbilt Parent Assessment Scales (initial)

Follow-Up Packet - 2 each - Teacher and Parent Vanderbilt Follow-Up Assessment Scales

Scoring Instructions - NICHQ Vanderbilt Forms

 

ADHD Handouts

 

Adderall Patient Information (2/9/2005)

ADHD Evaluation Timeline

ADHD Parenting Tips

Does My Child Have ADHD?

ADHD Internet Resources

Attention Deficit Disorder (ADD, ADHD, Hyperactivity, Short Attention Span) (Barton Schmitt)

 

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