Pediatric Forms

Providing Information to Help You Care for Your Child

Sports Physicals For Kids: What to Expect

Patient Forms:

If your child is a new patient, you will be asked to complete the following packet:

New Patient Packet in English:

Consent to Treatment English

Initial History Questionnaire English

New Patient Packet in Spanish:

Consent to Treatment Spanish

Initial History Questionnaire Spanish

Sports Physical Forms

PPE Health, physical, and medical forms

PPE – Supplement for Athletes with Disabilities

Special Olympics Medical Form

Special Olympics Medical Form Instructions

Well Child Visit Forms:

At your child's regular check-ups, you will be asked to fill out a questionnaire about your child's health. You can complete these forms in advance by downloading the appropriate questionnaire, filling it out and bringing the completed form to your child's appointment.

Newborn Visit English and Spanish:

Newborn Visit English

Newborn Visit Spanish

Two Week Visit English and Spanish:

Two Week Visit English

Two Week Visit Spanish

Two Month Visit English and Spanish:

ASQ-3 (2 Month Questionnaire)

Staying Healthy Assessment

Edinburgh English

Screening Checklist

ASQ-3 (2 Month Questionnaire Spanish)

Staying Healthy Assessment Spanish

Edinburgh Spanish

Screening Checklist Spanish

6 Month Visit English and Spanish:

Pediatric TB English and Spanish

ASQ-3 (6 month Questionnaire)

Staying Healthy Assessment

Edinburgh English

Screening Checklist

ASQ-3 (6 Month Questionnaire-Spanish)

Staying Healthy Assessment-Spanish

Edinburgh-Spanish

Screening Checklist-Spanish

9 Month Visit English and Spanish:

Pediatric TB English and Spanish

ASQ-3 (7-12 Month Questionnaire)

Staying Healthy Assessment

Screening Checklist

ASQ-3 (7-12 Month Questionnaire-Spanish)

Staying Healthy Assessment-Spanish

Screening Checklist-Spanish

12 Month Visit English and Spanish:

Pediatric TB English and Spanish

ASQ-3 (12 Month Questionnaire)

Staying Healthy Assessment

Screening Checklist

Dental Care Interest Card

ASQ-3 (12 Month Questionnaire-Spanish)

Staying Healthy Assessment-Spanish

Screening Checklist-Spanish

15 Month Visit English and Spanish

Pediatric TB English and Spanish

ASQ-3 (16 Month Questionnaire)

Staying Healthy Assessment

Screening Checklist

ASQ-3 (16 Month Questionnaire-Spanish)

Staying Healthy Assessment-Spanish

Screening Checklist-Spanish

18 Month Visit English and Spanish:

Pediatric TB English and Spanish

ASQ-3 (18 Month Questionnaire)

Staying Healthy Assessment

Screening Checklist

M-Chat

ASQ-3 (18 Month Questionnaire-Spanish)

Staying Healthy Assessment-Spanish

Screening Checklist-Spanish

M-Chat-Spanish

2 Year Visit English and Spanish:

Pediatric TB English and Spanish

ASQ-3 (24 month Questionnaire)

Staying Healthy Assessment

Screening Checklist

M-Chat

Dental Care Interest Card

ASQ-3 (24 Month Questionnaire-Spanish)

Staying Healthy Assessment-Spanish

Screening Checklist-Spanish

M-Chat-Spanish

2 ½ Year Visit English and Spanish:

Pediatric TB English and Spanish

ASQ-3 (30 month Questionnaire)

Staying Healthy Assessment

Screening Checklist

Dental Care Interest Card

ASQ-3 (30 Month Questionnaire-Spanish)

Staying Healthy Assessment-Spanish

Screening Checklist-Spanish

3 Year Visit English and Spanish:

Pediatric TB English and Spanish

ASQ-3 (36 month Questionnaire)

Staying Healthy Assessment

Screening Checklist

Dental Care Interest Card

ASQ-3 (36 Month Questionnaire-Spanish)

Staying Healthy Assessment-Spanish

Screening Checklist-Spanish

4 Year Visit English and Spanish:

Pediatric TB English and Spanish

ASQ-3 (48 Month Questionnaire)

Staying Healthy Assessment

Screening Checklist

Dental Care Interest Card

ASQ-3 (48 Month Questionnaire-Spanish)

Staying Healthy Assessment-Spanish

Screening Checklist-Spanish

5 - 8 Year Visit English and Spanish:

Pediatric TB English and Spanish

Staying Healthy Assessment

Screening Checklist

Dental Care Interest Card

Staying Healthy Assessment-Spanish

Screening Checklist-Spanish

9 - 11 Year Visit English and Spanish:

Pediatric TB English and Spanish

Staying Healthy Assessment

Screening Checklist

Dental Care Interest Card

Staying Healthy Assessment-Spanish

Screening Checklist-Spanish

12-17 Year Visit English and Spanish:

Staying Healthy Assessment

Screening Checklist

Dental Care Interest Card

PHQ-9 Modified for Teens

Staying Healthy Assessment-Spanish

Screening Checklist-Spanish

Pediatrics Resources & Downloads:

An Open Letter from Your Pediatric Providers During COVID-19 - Download

Top Tips for Kids During COVID-19 by Karisma Ebora, CPNP-PC - Download

Team Spirit During Distance Learning by Janine Arbelaez, Psy.D, LMFT -
Download

RRH Podcasts on Children's Health:

Importance of Well Visits, Vaccinations, Physicals, Summer Safety
Featuring: Jennifer Prince, DO

Recognizing Flu Symptoms in Children
Featuring: Andrew Modic, MD

Type 1 Diabetes in Children - What is it and What to Look Out For Featuring: Jesse Allande, RN

Other Downloads:

Childhood Lead Poisoning Prevention (Kern County Public Health) -
Fact Sheet (English/Spanish)

Making Healthier Choices to Help Keep Your Child Safe From Lead (Kern County Public Health) - (English)

Making Your Home Lead Safe (Kern County Public Health) - (English)

Protect Your Child From Lead (Kern County Public Health) -(English/Spanish)

Useful Links

www.safekids.org/ - Think of us as your go-to source for safety information and safety tips. On this site, you will find tips from top safety experts on everything you need to keep kids of any age safe from preventable injuries.