This page has the forms that we may want you to complete before some office visits. We’ve posted them here so that if our office staff informs you any of them will be necessary, you can print them and fill them out ahead of time, and bring them to the visit. Please fill in with dark ink, as lighter pencil will not scan as well. We hope this will help your visit with us run more smoothly.

We require 5 business days to process forms that require a physician’s signature.

If you have been instructed to submit your form electronically, click here

Administrative Forms

• Request for old records to be sent to Woodinville Pediatrics-ONLINE FORM
• New Patient Packet rev 8_2020
• Request for Medical Records Release
• Consent to Treat rev 1_2018
• Consent to Share Medical Information with Parent or Guardian (for 18 year and older patient)
• Insurance Update
• Patient Registration rev_8_2020
• Lab Result Authorization rev 1_2018
• Office Policies
• Patient Health History
  
• Billing and Financial Policies
• Notice of Privacy Practices rev 1_2018

Clinical Forms and Questionnaires

• Abdominal Pain Questionnaire
• Asthma Control Test 4-11 years age
• Asthma Control Test 12+ years age
• Constipation Questionnaire
• Concussion intake (for 5 to under 13 year old)
• Concussion intake (for 13 years and older)
• Headache Questionnaire
• Influenza Questionnaire 2020-2021
• Food Record (Diet Diary)
• MCHAT-R Questionnaire
• MRSA Management (From Seattle Children’s Hospital)
• Recurrent Fevers Questionnaire
• Relaxation Tip Sheet
• Syncope Questionnaire
• Travel Questionnaire –We request you submit this form at least 2 weeks in advance of travel
• Washington State Dept of Health Newborn Screen (Sickle Cell) Results Request Form

Mood Questionnaires

• PHQ_9 Depression Questionnaire
• Short Mood and Feelings Questionnaire-Self
• Short Mood and Feelings Questionnaire-Parent
• SCARED Anxiety questionnaire-Child
• SCARED-Anxiety questionnaire-Parent

School Forms

• School Forms, various school districts
• School Forms for Students on Insulin Injections
• School Forms for Students Wearing an Insulin Pump
• School Medication Authorization Form
• Immunization Exemption Form
• Medical Release for Wrestler With Skin Lesion

ADD/ADHD Forms

• ADHD Questionnaire (For Initial Evaluation, 29 pages. You do not need to download other forms here unless more than 1 copy of Teacher Questionnaires-Vanderbilt and Conners are needed.
• Conners Parent Questionnaire (2 pages)
• Conners Teacher Questionnaire (2 pages)
• Vanderbilt Questionnaire Parent Initial (2 pages)
• Vanderbilt Questionnaire-Teacher Initial (2 pages)
• Vanderbilt Questionnaire-Parent Follow Up
• Vanderbilt Questionnaire-Teacher Follow Up
• Adult ADHD Self Reporting Scale (1 page)

Practice Policies

You can view our practice policies on our Practice Policies page .