Postnatal Maternal Screening
Moms should complete this form 7-10 days after the delivery of your infant.  You will discuss the results of this screening questionnaire with your child’s pediatrician at the 2-week check up.  After having completed the questionnaire, should you feel that your responses warrant an expedited discussion with a physician, please call our office immediately to schedule an appointment.

Both new patients and established patients with a change in family health history should download, complete this form, and bring it to your child's next appointment.

 Family Health & Genetic History

If your child is 16-30 months old and you are concerned that your child might show some autistic tendencies:

1) First schedule an appointment with your child's pediatrician.

2) Then, complete this online screening questionnaire.

Your child's pediatrician will review the results with you and address any concerns at your child's scheduled visit.

Complete this form only if your child’s doctor is concerned about asthma or reactive airway disease. These screening questionnaires are reviewed by your child’s pediatrician and should be completed within 2 weeks of your child’s next scheduled appointment. Forms completed too far in advance may no longer be accurate or reflect appropriate concerns.

Asthma / Reactive Airway Disease Screening (Ages 1 - 11)

If you are concerned that your child may have asthma or reactive airway disease and you would like to complete this form, we ask that you first schedule an appointment and then complete this form within 2 weeks of that scheduled appointment.

Complete this form if your child has already been diagnosed with asthma or reactive airway disease. These questionnaires are reviewed by your child’s pediatrician and should be completed within 2 weeks of your child’s next scheduled appointment. Forms completed too far in advance may no longer be accurate or reflect appropriate concerns.

Asthma / Reactive Airway Disease Control Questionnaire
(Ages 1 - 11)

Please have your adolescent complete the appropriate online form under the Tweens & Teens tab on this website.

Complete the Initial Screening form if your child’s doctor is concerned that your child has symptoms consistent with attention deficit hyperactivity disorder (ADHD).

Complete the Follow-up Screening form if your child has already been diagnosed with ADHD or a subtype of ADHD and has a follow-up visit scheduled within 2 weeks of completing this form.

Either form should be completed within 2 weeks of your child’s next scheduled appointment. Forms completed too far in advance may no longer be accurate or reflect appropriate concerns.

Parents:

If your child's teacher has access to the internet, download, print, and complete this form:  Teacher Evaluation Instructions, and then give it to two of your child's teachers.  (There are 2 copies in this download)

If your child's teacher does not have access to the internet, download and print this Teacher Evaluation Screen. There are two copies of the questionnaire in this download. Distribute each to two different teachers as instructed by your child’s pediatrician. Bring these completed forms to your child’s next visit.

Teachers:

If you have been asked to complete a Teacher Evaluation Form, you can either download and complete a paper form--link above (and then give the completed form to the student's parent to bring to the next visit) or complete an online version of the same form (this form will be sent directly to the child's pediatrician).

To complete an online form, you will need to ask the student's parents for the following information:
* Office location of student's appointment
(Barrington or Crystal Lake)
* Date of student's scheduled appointment.

If this is the first time you are completing an ADHD Evaluation form for this student, complete the Initial Screening form.

If you have previously completed an Initial Screening form for this student, and you are being asked to complete a follow-up form, complete the Follow-up Screening form here.