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.
COVID-19 Vaccine
Your whole family, ages 5 to 64, can get vaccinated at Metropolitan Pediatrics. Call 1-833-PDX-KIDS to schedule, or book your visit online. Note: Metropolitan Pediatrics is unable to provide vaccines for individuals covered by Medicare or Kaiser HMO.
COVID-19 Vaccine Screening & Consent Form
The COVID-19 Vaccine Screening & Consent Form helps us determine if there is any reason you should not get the COVID-19 vaccine. You may complete it and bring it with you to your appointment. Paper copies are also available at the clinic if needed.
COVID-19 Vaccine Aftercare
The COVID-19 Vaccine Aftercare handout goes over what to do if you have a reaction to the COVID-19 vaccine and how to share your vaccine experience with the FDA/CDC for ongoing safety monitoring.
COVID-19 Vaccine Emergency Use Authorization (EUA) Fact Sheets for Recipients
The COVID-19 Vaccine EUA Fact Sheets provide certain vaccine-specific EUA information to help people make an informed decision about vaccination. The fact sheets are similar in purpose and content to vaccine information statements (VISs) for licensed vaccines.
Clinical Forms
MyHealth Proxy Access Request
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. Patients 14 and older must give permission for a parent or legal guardian to have access to their MyHealth account, or they can have their own private MyHealth account.
Learn more about MyHealth and viewing family member accounts.
Patient Intake Form
The Patient Intake Form is a detailed questionnaire about your child and family’s medical history.
Other languages: Spanish/Español
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 the form to your computer, complete it, save a copy for your records, and print and return it by mail or fax to the clinic. Although you can fill forms in online, your changes might 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
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
The Postnatal Depression Screen is designed to identify parents who may be experiencing symptoms associated with Postpartum Depression.
Other languages: Spanish/Español
9 Month Visit
9 Month ASQ
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.
Other languages: Spanish/Español
18 Month Visit
M-CHAT-R
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.
Other languages: Spanish/Español
18 Month ASQ
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.
Other languages: Spanish/Español
2 Year Visit
M-CHAT-R
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.
Other languages: Spanish/Español
24 Month ASQ
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.
Other languages: Spanish/Español
2½ Year Visit
30 Month ASQ
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.
Other languages: Spanish/Español
6-10 Year Visit
Sports Pre-participation Questionnaire
The Sports Pre-participation Questionnaire helps assess and ensure patients’ safe participation in organized sports and other physical activities.
Other languages: Spanish/Español
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 (ages 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
The Pediatric Symptom Checklist is a standardized screening tool, in which parents rate how they perceive their adolescent.
Other languages: Spanish/Español
Sports Pre-participation Questionnaire
The Sports Pre-participation Questionnaire helps assess and ensure patients’ safe participation in organized sports and other physical activities.
Other languages: Spanish/Español
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 (ages 14+)
The Confidential Health History is a questionnaire completed by patients at each preventive exam during the 14-18 age range.
Pediatric Symptom Checklist
The Pediatric Symptom Checklist is a standardized screening tool, in which parents rate how they perceive their adolescent.
Other languages: Spanish/Español
Sports Pre-participation Questionnaire
The Sports Pre-participation Questionnaire helps assess and ensure patients’ safe participation in organized sports and other physical activities.
Other languages: Spanish/Español
More Ages & Stages Questionnaires
12 Month ASQ
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.
Other languages: Spanish/Español
36 Month ASQ
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.
Other languages: Spanish/Español
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.
Other languages: Spanish/Español
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
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.
Other languages: Spanish/Español
Patient Information
The Patient Information form is used to collect patient/parent demographic and insurance information.
Other languages: Spanish/Español
Treatment Consent
The Treatment Consent describes care at Metropolitan Pediatrics, including our confidentiality obligations, insurance agreements, appointment reminders, after-hours assistance, and grievance procedure.
Other languages: Spanish/Español
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.
