Mobile Full Width Tablet Small Desktop
  • About
    • About Us
    • Our Providers
  • Our Services
    • 24-Hour Assistance
    • Meet & Greets
    • Newborn & Infant Services
      • Newborn Circumcision
      • Lactation Support
      • Frenotomy
    • Well Exams
      • Resilience
      • Comfort Promise
    • Behavioral Health
    • Complex Care Management
    • Foster Family Support
    • Pediatric Sports Medicine
    • Illness & Injury Care
    • In-House Labs
    • Medical Ear Piercing
    • Contraceptive Implant
  • Expectant Parents
  • Resources
    • Our Blog
    • Flu Prevention
    • Immunizations
    • Infant Immunization Videos
    • Visit & Vaccine Schedule
    • Anti-Racism Resources
    • Teen Resources
    • Wellness Resources
  • Patients
    • New Patient
    • Appointments
    • Zoom Video Visit
    • MyHealth Portal
    • Forms
    • Insurance
    • Billing & Financial Services
    • Pay My Bill
  • Locations
  • Appointments
Schedule AppointmentNew PatientsPay My Bill 1-833-PDX-KIDS
Beaverton

(503) 531-3434

Gresham

(503) 667-8878

Happy Valley

(503) 261-1171

NW Portland

(503) 295-2546

Bridgeport

(503) 214-2064

  • About
    • About Us
    • Our Providers
  • Our Services
    • 24-Hour Assistance
    • Meet & Greets
    • Newborn & Infant Services ›
      • Newborn Circumcision
      • Lactation Support
      • Frenotomy
    • Well Exams ›
      • Resilience
      • Comfort Promise
    • Behavioral Health
    • Complex Care Management
    • Foster Family Support
    • Pediatric Sports Medicine
    • Illness & Injury Care
    • In-House Labs
    • Medical Ear Piercing
    • Contraceptive Implant
  • Expectant Parents
  • Resources
    • Our Blog
    • Flu Prevention
    • Immunizations
    • Infant Immunization Videos
    • Visit & Vaccine Schedule
    • Anti-Racism Resources
    • Teen Resources
    • Wellness Resources
  • Patients
    • New Patient
    • Appointments
    • Zoom Video Visit
    • MyHealth Portal
    • Forms
    • Insurance
    • Billing & Financial Services
    • Pay My Bill
  • Locations
  • Appointments

Patient Forms

New Patient Forms

New Patient Packet
The New Patient Packet includes all the forms required to become a patient of Metropolitan Pediatrics. Please review our Treatment Consent, Billing & Financial Policies, and Notice of Privacy Practices prior to starting the packet.

Learn more about what to expect as a New Patient >>

Clinical Forms

MyHealth Proxy Access
The MyHealth Proxy Access Request gives a proxy, or person other than the patient, permission to access the patient’s MyHealth account and medical information available within MyHealth. Proxy access is available to the following:

  • Anyone an adult patient permits to be a proxy
  • Parent of a minor (birth parent or adoptive parent)
  • Legal guardian of a minor or adult
  • Parent or legal guardian of a developmentally disabled minor or adult patient

Patient Intake Form -OR- Formulario de ingreso del paciente 
The Patient Intake Form is a detailed questionnaire about your child and family’s medical history.

Behavioral Health Forms

Phone/Video Visit Consent
The Phone/Video Visit Consent contains important information about engaging in our clinic’s behavioral health services using the phone or internet. Please review it prior to your first virtual visit.

The following forms may be used as part of our evaluation process for a variety of behavioral health concerns, such as ADHD, anxiety, or mood challenges. Your answers will give our team valuable insight into the child or teen’s medical and family history, functioning at home and school, and any concerns related to sleep, attention, and concentration. Please follow your pediatrician’s guidance regarding which forms to complete.

INSTRUCTIONS: Please download a copy of the form to your computer, complete it, save it for your records, and print and return it by mail or fax to the clinic. Although you can fill forms in online, what you enter does not save when downloaded.

Parent Forms

  • Child & Family Information Form
  • Vanderbilt Assessment Scale (Vanderbilt-Caregiver)
  • Screen for Child Anxiety Related Disorders (SCARED-Caregiver)
  • Pediatric Symptom Checklist
  • Pediatric Sleep Questionnaire
  • Children’s Sleep Habits: Ages 5-12
  • Child & Adolescent Trauma Screen (CATS-Caregiver): Ages 3-6
  • Child & Adolescent Trauma Screen (CATS-Caregiver): Ages 7-17

Patient Forms

  • ADHD Self-Report Symptom Checklist
  • Screen for Child Anxiety Related Disorders (SCARED-Patient)
  • Adolescent Sleep Hygiene Scale: Ages 13+
  • Child & Adolescent Trauma Screen (CATS-Patient): Ages 7-17

Teacher Forms

  • Vanderbilt Assessment Scale (Vanderbilt-Teacher)
  • Teacher Questionnaire

Acute Visit Forms

Mood & Stress

PHQ-2 Questionnaire
The PHQ-2 Questionnaire quickly screens all patients ages 11 and older for signs of depression.

PHQ-9 Questionnaire
The PHQ-9 Questionnaire is a more in-depth screening tool for the presence and severity of depressive disorder symptoms.

Mood & Stress Questionnaire
The Mood & Stress Questionnaire is completed by patients who are on antidepressants or anti-anxiety medications to check how they have been feeling emotionally during the past two weeks.

Well Visit Forms

1-6 Month Visit

Postnatal Depression Screen -OR- Cuestionario de depresión postparto
The Postnatal Depression Screen is designed to identify parents who may be experiencing symptoms associated with Postpartum Depression.

9 Month Visit

9 Month ASQ -OR- Cuestionario de 9 meses
The Ages & Stages Questionnaire (ASQ) is designed to screen young children for developmental delays—that is, to identify children who need further evaluation and those who are developing typically.

18 Month Visit

M-CHAT-R -OR- Cuestionario modificado de detección temprana de autismo
The M-CHAT-R assesses your child’s risk for autism spectrum disorders. Metropolitan Pediatrics screens all children at their 18-month appointment, and again at 24 months.

18 Month ASQ -OR- Cuestionario de 18 meses
The Ages & Stages Questionnaire (ASQ) is designed to screen young children for developmental delays—that is, to identify children who need further evaluation and those who are developing typically.

2 Year Visit

M-CHAT-R -OR- Cuestionario modificado de detección temprana de autismoThe M-CHAT-R assesses your child’s risk for autism spectrum disorders. Metropolitan Pediatrics screens all children at their 18-month appointment, and again at 24 months.

24 Month ASQ -OR- Cuestionario de 24 meses
The Ages & Stages Questionnaire (ASQ) is designed to screen young children for developmental delays—that is, to identify children who need further evaluation and those who are developing typically.

2½ Year Visit

30 Month ASQ -OR- Cuestionario de 30 meses
The Ages & Stages Questionnaire (ASQ) is designed to screen young children for developmental delays—that is, to identify children who need further evaluation and those who are developing typically.

6-10 Year Visit

Sports Pre-participation Questionnaire -OR- Examen previo a la participación en deportes en la escuela
The Sports Pre-participation Questionnaire helps assess and ensure patients’ safe participation in organized sports and other physical activities.

11-13 Year Visit

Adolescent Annual Questionnaire
The Adolescent Annual Questionnaire is completed by all adolescent patients at least once a year because substance use and mood can affect your health.

Confidential Health History (11-13)
The Confidential Health History is a questionnaire completed by patients at each preventive exam during the 11-13 age range.

Pediatric Symptom Checklist -OR- Lista de síntomas pediátricos
The Pediatric Symptom Checklist is a standardized screening tool, in which parents rate how they perceive their adolescent.

Sports Pre-participation Questionnaire -OR- Examen previo a la participación en deportes en la escuela
The Sports Pre-participation Questionnaire helps assess and ensure patients’ safe participation in organized sports and other physical activities.

14-18 Year Visit

Adolescent Annual Questionnaire
The Adolescent Annual Questionnaire is completed by all adolescent patients at least once a year because substance use and mood can affect your health.

Confidential Health History (14+)
The Confidential Health History is a questionnaire completed by patients at each preventive exam during the 14-18 age range.

Pediatric Symptom Checklist -OR- Lista de síntomas pediátricos
The Pediatric Symptom Checklist is a standardized screening tool, in which parents rate how they perceive their adolescent.

Sports Pre-participation Questionnaire -OR- Examen previo a la participación en deportes en la escuela
The Sports Pre-participation Questionnaire helps assess and ensure patients’ safe participation in organized sports and other physical activities.

More Ages & Stages Questionnaires

12 Month ASQ -OR- Cuestionario de 12 meses
The Ages & Stages Questionnaire (ASQ) is designed to screen young children for developmental delays—that is, to identify children who need further evaluation and those who are developing typically. We do not require this form at your child’s 12-month visit; however, many parents choose to complete it and bring it with them to discuss their baby’s development.

36 Month ASQ -OR- Cuestionario de 36 meses
The Ages & Stages Questionnaire (ASQ) is designed to screen young children for developmental delays—that is, to identify children who need further evaluation and those who are developing typically. Our NW Portland Office requires this form at your child’s 3-year visit.

Administrative Forms

Authorization to Release Medical Records
The Authorization to Release Medical Records grants Metropolitan Pediatrics permission to send, receive, or verbally exchange medical records with another person or practice of your request.

Genetic Privacy Notice
The Genetic Privacy Notice regards the decision whether to use your child’s health information or biological samples for future genetic research.

Notice of Privacy Practices -OR- Aviso de prácticas de privacidad
The Notice of Privacy Practices describes how medical information about you may be used and disclosed and how you can get access to this information.

Patient Information -OR- Formulario de información del paciente
The Patient Information form is used to collect patient/parent demographic and insurance information.

Treatment Consent -OR- Consentimiento de tratamiento
The Treatment Consent describes care at Metropolitan Pediatrics, including our confidentiality obligations, insurance agreements, appointment reminders, after-hours assistance, and grievance procedure.

Billing & Financial Policies
The Billing & Financial Policies outlines Metropolitan Pediatrics’ billing and financial policies for any charges resulting from care.

Financial Assistance Application
The Financial Assistance Application is a request to be considered for reduced monthly payments or discounts due to a recent change in financial circumstances or the inability to pay your bill.


Latest News

COVID-19 Vaccine FAQ

Coronavirus (COVID-19) FAQ

COVID-19 Vaccine Update

#MyWhy: Dr. Sari Shares Her COVID-19 Vaccine Experience

Q&A with Dr. Allison Baynham, Our Newest IBCLC

New Patients

Thank you for choosing Metropolitan Pediatrics as your child’s Medical Home! Our physicians and staff are pleased to have the opportunity to build a relationship with you, your child, and family.

Get Started

Office Locations

Beaverton
15455 NW Greenbrier Parkway
Suite 111
Beaverton, OR 97006

Phone (503) 531-3434
Fax (503) 645-4544

Bridgeport
7213 SW Hazelfern Road
Tigard, OR 97224

Phone (503) 214-2064
Fax (503) 598-3600

Gresham
25050 SE Stark Street
Suite 300
Gresham, OR 97030

Phone (503) 667-8878
Fax (503) 667-0310

Happy Valley – Johnson Creek
9300 SE 91st Avenue
Suite 200
Happy Valley, OR 97086

Phone (503) 261-1171
Fax (503) 253-5989

Happy Valley – Sunnyside
16144 SE Happy Valley Town Center Drive
Suite 210
Happy Valley, OR 97086

Phone (503) 486-7040
Fax (503) 658-3377

NW Portland
1130 NW 22nd Avenue
Suite 320
Portland, OR 97210

Phone (503) 295-2546
Fax (503) 790-1248

Popular Links

  • About Us
  • Our Providers
  • Our Services
  • Expectant Parents
  • New Patient
  • MyHealth Portal
  • Insurance
  • Pay My Bill
  • 24-Hour Assistance
  • Meet & Greets
  • Newborn & Infant Services
  • Well Exams
  • Appointments
  • Privacy Practices
  • Careers
© 2021 Copyright Metropolitan Pediatrics | Website terms of use

FACE MASKS REQUIRED!

Please AVOID wearing masks with a valve or vent.

These types of masks do not prevent COVID-19 from spreading to

others. If you visit Metropolitan Pediatrics wearing one, we will

provide a disposable mask for you to wear over the valve.

All clinic visitors (age 2+) must wear a face mask or cloth face covering AT ALL TIMES while inside Metropolitan Pediatrics.