Priority Pediatrics PC

Available Forms

1. NEW Patient Online Intake History Form for Dr. T 2. ESTABLISHED Patient Online Interim History Form for Dr. T 3. Lead Exposure Risk Questionnaire for parent to complete for Dr. T 4. Request to Transfer Medical Records to Priority Pediatrics 5. Pediatric Symptom Checklist for PARENTS of 11-18 Year Olds to Complete for Dr. T 6. Pediatric Symptom Checklist for YOUTH ages 11-18 Years to Complete for Dr. T 7. Adolescent Mood Questionnaire for the Teen to complete for Dr. T 8 Side Effect Patient Check List 9. Tuberculosis (TB) Exposure Risk Questionnaire to complete for Dr. T 10. Pediatric Sleep Questionnaire / PSQ for parent to complete for Dr. T

5. Pediatric Symptom Checklist for PARENTS of 11-18 Year Olds to Complete for Dr. T

A PARENT Survey from Dr. T for children between the ages of 11 and 18 years

Please register on my Updox Portal BEFORE starting this questionnaire, if you have not already previously registered, so that your work can be saved and completed in more than one seating if needed. Once you are registered on the Portal, you will be able to retrieve past sent forms and resend if needed. Also do NOT use your BACK Button or REFRESH, or you will lose all your Form information and need to start over. When completed, click SEND and the form will come securely to me. Thank you. Dr. T

Name of Parent(s) completing checklist *

Name of Child *

Date completed *

Please indicate under the heading that best describes how you see your child: No, Sometimes, Often.

1. Complains of aches or pains *

Never (0)

Sometimes (1)

Often (2)

2. Spends more time alone *

No (0)

Sometimes (1)

Often (3)

3. Tires easily; has little energy *

No (0)

Sometimes (1)

Often (3)

4. Very fidgety; unable to sit still *

No (0)

Sometimes (1)

Often (3)

5. Has trouble with teacher *

No (0)

Sometimes (1)

Often (3)

6. Less interested in school *

No (0)

Sometimes (1)

Often (3)

7. Acts as if driven by a motor *

No (0)

Sometimes (1)

Often (3)

8. Daydreams too much *

No (0)

Sometimes (1)

Often (3)

9. Distracted easily *

No (0)

Sometimes (1)

Often (3)

10. Is afraid of new situations *

No (0)

Sometimes (1)

Often (3)

11. Feels sad, unhappy *

No (0)

Sometimes (1)

Often (3)

12. Is irritable, angry *

No (0)

Sometimes (1)

Often (3)

13. Feels hopeless *

No (0)

Sometimes (1)

Often (3)

14. Has trouble concentrating *

No (0)

Sometimes (1)

Often (3)

15. Less interested in friends, withdrawn. *

No (0)

Sometimes (1)

Often (3)

16. Fights with other children *

No (0)

Sometimes (1)

Often (3)

17. Absent from School *

No (0)

Sometimes (1)

Often (3)

18. School grades are dropping *

No (0)

Sometimes (1)

Often (3)

19. Down on him/herself *

No (0)

Sometimes (1)

Often (3)

20. Doctor visits & finds nothing wrong *

No (0)

Sometimes (1)

Often (3)

21. Has trouble sleeping *

No (0)

Sometimes (1)

Often (3)

This can be either initiating sleep or remaining asleep through the night or both.

22. Worries a lot *

No (0)

Sometimes (1)

Often (3)

23. Wants to be with parent(s) more than before *

No (0)

Sometimes (1)

Often (3)

24. Feels that he/she is bad *

No (0)

Sometimes (1)

Often (3)

25. Takes unnecessary risks *

No (0)

Sometimes (1)

Often (3)

26. Gets hurt frequently *

No (0)

Sometimes (1)

Often (3)

27. Seems to be having less fun *

No (0)

Sometimes (1)

Often (3)

28. Acts younger than children of the same age *

No (0)

Sometimes (1)

Often (3)

29. Does not listen to rules *

No (0)

Sometimes (1)

Often (3)

30. Does not show feelings *

No (0)

Sometimes (1)

Often (3)

31. Does not understand other people's feelings *

No (0)

Sometimes (1)

Often (3)

32. Teases others *

No (0)

Sometimes (1)

Often (3)

33. Blames others for his/her troubles *

No (0)

Sometimes (1)

Often (3)

34. Takes things that do not belong to him/her *

No (0)

Sometimes (1)

Often (3)

35. Refuses to share with others *

No (0)

Sometimes (1)

Often (3)

36. During the past three months, has shared that he/she has thought of killing self *

No (0)

Sometimes (1)

Often (3)

37. Has ever tried to kill him/herself *

No (0)

Sometimes (1)

Often (3)

Please elaborate on any aspects of the above answers that you wish.

* Required field