Forms

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• New patient packet– please bring completed forms to the first visit
• Change of address form
• 2018 Asthma Form – should be filled out at yearly for all asthma patients
• HIPAA Policy
• Medical Records Release Form 

Sports and School Forms

• Kentucky sports form grades 6-8
• Kentucky sports from grades 9-12
• Ohio sports form

ADHD Forms
The Vanderbilt Parent and Teacher Assessment Forms must be filled out and mailed to our office prior to an appointment to discuss if you child may have ADHD.   The Vanderbilt Parent and Teacher Followup forms must be filled out and mailed to our office for any patient diagnosed with ADHD prior to a well check or an ADHD check.  The followup forms should be filled out at least yearly for any patient who has been diagnosed with ADHD

• Vanderbilt Teacher Initial Assesment Form
• Vanderbilt Parent Initial Assessment Form
• Vanderbilt Teacher Followup Form
• Vanderbilt Parent Followup Form
  

ADHD Treatment Contract

Medications used for the treatment of ADHD are classified as stimulants and are tightly controlled by state and federal law and we are required to check state registers to assess frequency of medication refills and prescribers for ADHD medication. Your understanding and cooperation with the guidelines in this treatment contract are required for your child to receive medication for the treatment of their ADHD the Northern Kentucky Pediatric Group (NKYPG).

• ADHD Treatment contract

Anxiety/Depression Forms
The Scared forms have a questionnaire for both the parent(s) and child to complete. Please complete the scared forms AND the PHQ-9 for every visit.

• Scared parent & child
• PHQ-9
• Depression and Anxiety Contract