New Patient
- 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.
- New Patient Packet
- The New Patient Packet includes all of the forms required to become a patient of Metropolitan Pediatrics. Please review our Treatment Consent, Credit Policy, and Notice of Privacy Practices prior to your first appointment.
- 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.
- 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.
- 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.
Additional Forms
Behavioral Health
Behavioral Health > Intake Packet
The Intake Packet includes several detailed questionnaires needed for your first behavioral health appointment. Your answers will give our staff valuable insight into your child or teen’s medical and family history, including any concerns related to sleep, attention, and concentration.
Behavioral Health > 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.
Vanderbilt Teacher Assessment
The Vanderbilt Teacher Assessment is a teacher-completed rating scale and questionnaire that assists us in better understanding your child’s functioning within the school setting. It is part of our evaluation process for attention deficit hyperactivity disorder (ADHD).
Billing & Financial
- Credit Policy -OR- Política de crédito
- The Credit Policy 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.
MyHealth Patient Portal
- 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:
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- Anyone an adult patient permits to be a proxy (spouse)
- Parent of a minor (birth parent or adoptive parent)
- Legal guardian of a minor or adult
- Parent/legal guardian of a developmentally disabled minor or adult patient
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 to 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 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.
- 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 to 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 to 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 to 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.
