Routine and Sports Physicals

Below you will find handouts about your child's expected and anticipated development, and questionnaires that will help your doctor assess your child's health and development at the next well visit.  Please download, complete, and bring the age-appropriate handouts and questionnaires to your child's next well visit.

 

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There are no questionnaires that need to be completed in advance of these visits. Download and read the following information handouts in advance of your child's visit. If you have any questions or concerns, bring them to discuss with your child's doctor:
2 month old - Parent Handout
4 month old - Parent Handout
6 month old - Parent Handout
9 month old - Parent Handout

Developmental Milestones (0-12 months)

Additional Materials
How to Prevent Tooth Decay
Baby Walkers: A Dangerous Choice
Choking Prevention
How to Respond to a Choking Emergency
Home Safety
 

 

Download, print, and complete this form within 2 weeks of your child’s 12 month and 15 month physicals.
  12 and 15 month old Questionnaire

In addition, here is an informational handout for you to download and read:
  12 month old - Parent Handout
  15 month old - Parent Handout

  Developmental Milestones (12-15 months)

 

1) First, complete this online develepmental screening questionnaire:
18 and 24 month Developmental Screen

2) Then, download, print, and complete this form within 2 weeks of your child’s 18 month and 24 month physicals.
18 and 24 month old Parent Questionnaire

In addition, here are additional materials and an informational handout for you to download and read:
18 month old - Parent Handout
24 month old - Parent Handout
30 month old - Parent Handout

Developmental Milestones (18-36 months)

 

Download, print, and complete this form within 2 weeks of your child’s 3 year and 4 year physicals.
3 and 4 year old Questionnaire

In addition, here are additional materials and an informational handout for you to download and read:

3 year old - Parent Handout
4 year old - Parent Handout

Developmental Milestones (3 - 5 years old)

 

Download, print, and complete this form within 2 weeks of your child’s 5 year and 6 year physicals.
5 and 6 year old Questionnaire

In addition, here are additional materials and an informational handout for you to download and read:

5 and 6 year old - Parent Handout

Development (gradeschool ages)

 

Download, print, and complete this form within 2 weeks of your child’s routine physicals between 7 and 11 years of age.
7 through 11 year old Questionnaire

In addition, here are additional materials and an informational handout for you to download and read:

7 and 8 year old - Parent Handout
7 and 8 year old - Children Handout
9 and 10 year old - Parent Handout
9 and 10 year old - Children Handout
11 year old - Parent Handout
11 year old - Children Handout

Development (gradeschool ages)

 

Download, print, and complete this form within 2 weeks of your adolescent’s routine physical.
  12 through 17 year old Parent Questionnaire
Do not forget to have your adolescent complete the
    Adolescent Wellness Questionnaire
under the Tweens & Teens tab on this website.

 

In addition, here is an informational handout for you to download and read:
  12 - 14 year old - Parent Handout
  12 - 14 year old - Adolescent Handout
  15 - 17 year old - Parent Handout
  15 - 17 year old - Adolescent Handout

  Development (Adolescents)


 

Now that your child is 18 years old, please have your adolescent complete the Adolescent Wellness Questionnaire under the Tweens & Teens tab on this website.
 

Below is the link to the Vaccine Authorization Form.  Please download, complete, and bring this to your child's next well visit.
Vaccine Authorization Form

 

 

Online Screening Forms

 

We know you worry. You're a parent and that's what you do. But ensuring you and your kids are healthy can be a little less stressful now. Our online screening tools can give you piece of mind and put you on the right track to addressing your concerns. First, schedule an appointment with your child's pediatrician. Then complete the appropriate online screening questionnaire within two weeks of your child's appointment. At that visit, your doctor will explain the results and talk with you about any next steps. It's easy, completely confidential, and most importantly, it works.

 

 

Postpartum Screening and Family History

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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

 

 

Asthma, Autism, and ADHD Screening

NOTE: Forms will not be reviewed without a scheduled appointment.

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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.

 

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