New Patient Forms
New Patient Packet
This packet includes all 6 forms you need to join Metropolitan Pediatrics. Welcome aboard! For expectant families, we ask that you wait to complete the forms until you know baby’s birthday. Please review our Treatment Consent, Billing & Financial Policies, and Notice of Privacy Practices before signing the forms.
COVID-19 Vaccine
Your whole family, ages five 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
This screener 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
This 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
These handouts 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 (VIS) for licensed vaccines.
Clinical Forms
MyHealth Proxy Access
This form 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.
Child & Family Health History
This form asks about diseases and health conditions in your family.
Other languages: Spanish/Español
Behavioral Health Forms
Phone/Video Visit Consent
This document 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
This questionnaire quickly screens all patients ages 11 and older for signs of depression.
PHQ-9 Questionnaire
This questionnaire is a more in-depth screening tool for the presence and severity of depressive disorder symptoms.
Mood & Stress Questionnaire
This 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.
1-6 Month Visit
Postnatal Depression Screen
This questionnaire is designed to identify parents who may be experiencing symptoms associated with Postpartum Depression.
Other languages: Spanish/Español
9 Month Visit
9-Month Ages & Stages Questionnaire
This questionnaire 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
This questionnaire assesses your child’s risk for autism spectrum disorders. Metropolitan Pediatrics screens all children at their 18-month visit and again at 24 months.
Other languages: Spanish/Español
18-Month Ages & Stages Questionnaire
This questionnaire 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
This questionnaire assesses your child’s risk for autism spectrum disorders. Metropolitan Pediatrics screens all children at their 18-month visit and again at 24 months.
Other languages: Spanish/Español
24-Month Ages & Stages Questionnaire
This questionnaire 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 Ages & Stages Questionnaire
This questionnaire 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
This 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
This questionnaire is completed by all adolescent patients at least once a year because substance use and mood can affect your health.
Other languages: Spanish/Español
Health History (Ages 11-13)
This questionnaire is completed by patients at each preventive exam during the 11-13 age range.
Other languages: Spanish/Español
Pediatric Symptom Checklist
This questionnaire is a standardized screening tool, in which parents rate how they perceive their adolescent.
Other languages: Spanish/Español
Sports Pre-participation Questionnaire
This 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
This questionnaire is completed by all adolescent patients at least once a year because substance use and mood can affect your health.
Other languages: Spanish/Español
Health History (Ages 14+)
This questionnaire is completed by patients at each preventive exam during the 14-18 age range.
Other languages: Spanish/Español
Pediatric Symptom Checklist
This questionnaire is a standardized screening tool, in which parents rate how they perceive their adolescent.
Other languages: Spanish/Español
Sports Pre-participation Questionnaire
This 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 Ages & Stages Questionnaire
This questionnaire 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 Ages & Stages Questionnaire
This questionnaire 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
Release of Protected Health Information (PHI)
This release gives Metropolitan Pediatrics permission to send, receive, or verbally exchange PHI with another person or practice of your request.
Other languages: Spanish/Español
Genetic Privacy Notice
This notice is about your right to say no to using your child’s health information or biological samples for genetic research.
Notice of Privacy Practices
This notice 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
This form is used to collect your family’s demographic and insurance information.
Other languages: Spanish/Español
Treatment Consent
This document 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
This document outlines Metropolitan Pediatrics’ billing and financial policies for any charges resulting from care.
Financial Assistance Application
This 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.
