Sometimes we may require the use of information from third parties to determine what services your child requires. Parents may bring this permission form into their child’s appointment:
Consent Form to Release Information
If your child is experiencing headaches or migraines, you may fill out a headache diary prior to the appointment – preferably for at least 2 weeks:
For Sleep Issues:
Parents, teachers, and adolescents can all utilize the option to complete the ADHD assessment forms (SNAP IV) online via: ADHD Rating Scales (follow instructions on website). These forms can then be printed and brought to the visit, or will be emailed directly to the office. Please also bring in report cards and other relevant assessments (psychology etc).
If you prefer written hard-copies, please find them below:
Is your child’s development normal? If you’re concerned about this or if this is the reason you’ve been referred to Richmond Pediatrics, you may be asked to fill in these questionnaires.
Ages & Stages – Developmental milestones
2 months, 4 Months, 6 Months, 8 Months, 9 Months, 10 Months, 12 Months, 14 Months, 16 Months, 18 Months, 20 Months, 22 Months, 24 Months, 27 Months, 30 Months, 33 Months, 36 Months, 42 Months, 48 Months, 54 Months, 60 Months
Failure to Thrive
If you are concerned about your child’s height, weight loss, size or dropping percentiles, you may be asked to bring growth charts or your child’s passport with growth measurements on it.
Please fill out the appropriate form to bring in to your next appointment with the pediatrician.
Questionnaire for Depression (KADS) (for teenagers)