Phone: (919) 774-7117
Fax: (919) 776-6715
1801 Doctors Drive Sanford, NC 27330

Download Forms

Baby with MirrorPlease print and complete applicable forms prior to your child’s visit. When you check-in, please let front staff know you have already completed the forms and brought them with you to the visit.

All forms are in pdf format and require the Adobe Reader. Get it for free.

For New Patients

For Existing Patients

Well Visit Forms:

  • Edinburgh Postnatal Depression Scale (EPDS) – to be completed at newborn visit, 1-2 week check, 2 month well check ( English | Spanish )
  • Modified Checklist for Autism in Toddlers (MCHAT) – to be completed at 18 month well check and 24 month well check ( English | Spanish )
  • Pediatric Symptoms Checklist (PSC) ( English | Spanish )
    to be completed by parent’s for well check visits for patients age 6-11 years
  • Youth Pediatric System Checklist (YPSC) ( English | Spanish )
    to be completed by adolescent for well check visits ages 11-18 years

Asthma Forms:

to be completed at each asthma follow-up appointment and well check in patient’s with asthma

Attention Deficit and Hyperactivity Disorder (ADHD) Forms

to be completed prior to visit to discuss possible ADD or ADHD or with medication changes or follow up appointments as directed by your pediatrician

  • Vanderbilt ADHD Diagnostic Teacher Rating Scale: to be completed by academic teacher ( English )
  • Vanderbilt Parent Assessment Scale: to be completed by parentsEnglish | Spanish )