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, Credit Policy, and Notice of Privacy Practices prior to starting the packet.
Flu Season 2020-21 Forms
Get flu shots together as a family at Metropolitan Pediatrics! Everyone in your household under age 65 (not covered by Medicare or Kaiser HMO) is welcome to receive a flu shot here.
Flu Clinic Registration -OR- Formulario de registro de Flu Clinic
The Flu Clinic Registration form is for family members of patients who would like to receive their flu shot at Metropolitan Pediatrics. Please allow one business day for us to add your information to the system before calling or expecting our call (choose your preference on the form) to schedule your flu shot.
- Expect a pre-screening phone call a day or two before your appointment.
- At the time of administration, you will also be asked to answer a few health questions and sign a consent form to proceed with vaccination.
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
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.
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.
