Web Forms

Pediatric Health Specialists

BRIGHT FUTURES PREVISIT QUESTIONNAIRE New Born-Bilingual

http://3.12.152.62/bright-futures-previsit-questionnaire-new-born-bilingual/ (Bilingual)

Pediatric Health Specialists

BRIGHT FUTURES 1 MONTH VISIT PREVISIT QUESTIONNAIRE-Bilingual

http://3.12.152.62/bright-futures-1-month-visit-previsit-questionnaire-bilingual/ (Bilingual)

Pediatric Health Specialists

BRIGHT FUTURES 9 MONTH VISIT PREVISIT QUESTIONNAIRE-Bilingual

http://3.12.152.62/bright-futures-9-month-visit-previsit-questionnaire-bilingual/ (Bilingual)

Pediatric Health Specialists

BRIGHT FUTURES PREVISIT QUESTIONNAIRE 12 Month-Bilingual

http://3.12.152.62/bright-futures-previsit-questionnaire-12-month-bilingual/ (Bilingual)

Pediatric Health Specialists

BRIGHT FUTURES PREVISIT QUESTIONNAIRE 18 Month-Bilingual

http://3.12.152.62/bright-futures-previsit-questionnaire-18-month-bilingual/ (Bilingual)

Pediatric Health Specialists

BRIGHT FUTURES PREVISIT QUESTIONNAIRE 24 Month-Bilingual

http://3.12.152.62/bright-futures-previsit-questionnaire-24-month-bilingual/ (Bilingual)

Pediatric Health Specialists

BRIGHT FUTURES PREVISIT QUESTIONNAIRE 36 Month-Bilingual

http://3.12.152.62/bright-futures-previsit-questionnaire-36-month-bilingual/ (Bilingual)

Pediatric Health Specialists

BRIGHT FUTURES PREVISIT QUESTIONNAIRE 48 Month-Bilingual

http://3.12.152.62/bright-futures-previsit-questionnaire-48-month-bilingual/ (Bilingual)

Pediatric Health Specialists

48 month screening form: Please complete before starting visit with your child’s healthcare provider.

http://3.12.152.62/48-month-asq/ (English)

Cuestionario: visita de 48 meses: Favor de completar antes de empezar la visita con el proveedor de salud de su niño.

http://3.12.152.62/48-month-asq-spanish/ (Español)

Pediatric Health Specialists

Autism screening form: Please complete before starting visit with your child’s healthcare provider.

http://3.12.152.62/m-chat/ (English)

Cuestionario: revisión de autismo: Favor de completar antes de empezar la visita con el proveedor de salud de su niño.

http://3.12.152.62/m-chat-spanish/ (Español)

Pediatric Health Specialists

Visit survey: Please take a minute to complete after your visit.

http://3.12.152.62/review-of-my-visit/ (English)

Cuestionario: revisión de su visita: Favor de tomar un minuto para completar después de su visita.

http://3.12.152.62/revision-de-mi-visita/ (Español)

Pediatric Health Specialists

9 Month screening forms for mothers: Please complete before starting visit with your child’s healthcare provider.

http://3.12.152.62/9-month-screening-forms-for-mothers/ (English)

Cuestionario: visita de 9 meses para madres: Favor de completar antes de empezar la visita con el proveedor de salud de su niño.

http://3.12.152.62/9-month-screening-forms-mothers-spanish/ (Español)

Pediatric Health Specialists

9 Month screening forms: Please complete before starting visit with your child’s healthcare provider.

http://3.12.152.62/9-month-asq-no-epds/ (English)

Cuestionario: visita de 9 meses para madres: Favor de completar antes de empezar la visita con el proveedor de salud de su niño.

http://3.12.152.62/9-month-asq-no-epds-spenish/ (Español)

Pediatric Health Specialists

12 month screening forms for mothers:: Please complete before starting visit with your child’s healthcare provider.

http://3.12.152.62/12-month-screening-forms-mothers/ (English)

Cuestionario: visita de 12 meses: Favor de completar antes de empezar la visita con el proveedor de salud de su niño.

http://3.12.152.62/12-month-screening-forms-mothers-spanish/ (Español)

Pediatric Health Specialists

12 months screening Forms: Please complete before starting visit with your child’s healthcare provider.

http://3.12.152.62/12-month-screening-forms-no-epds/ (English)

Cuestionario: visita de 12 meses para madres: Favor de completar antes de empezar la visita con el proveedor de salud de su niño.

http://3.12.152.62/12-month-screening-forms-no-epds-spanish/ (Español)

Pediatric Health Specialists

18 month screening forms: Please complete before starting visit with your child’s healthcare provider.

http://3.12.152.62/18-months-screening-forms/ (English)

Cuestionario: visita de 18 meses: Favor de completar antes de empezar la visita con el proveedor de salud de su niño.

http://3.12.152.62/18-months-screening-forms-spanish/ (Español)

Pediatric Health Specialists

24 month screening forms: Please complete before starting visit with your child’s healthcare provider.

http://3.12.152.62/24-month-screening-forms/ (English)

Cuestionario: visita de 24 meses: Favor de completar antes de empezar la visita con el proveedor de salud de su niño.

http://3.12.152.62/24-month-screening-forms-spanish/ (Español)

Pediatric Health Specialists

36 month screening form: Please complete before starting visit with your child’s healthcare provider.

http://3.12.152.62/36-month-asq/ (English)

Cuestionario: visita de 36 meses: Favor de completar antes de empezar la visita con el proveedor de salud de su niño.

http://3.12.152.62/36-month-asq-spanish/ (Español)

Pediatric Health Specialists

Teenage depression screening: Please complete before starting visit with your child’s healthcare provider.

http://3.12.152.62/patient-health-questionnaire-depression-%e2%80%90-modified-for-teens/ (English)

Cuestionario: depresión en adolescentes: Favor de completar antes de empezar la visita con el proveedor de salud de su niño.

http://3.12.152.62/patient-health-questionnaire-depression-%e2%80%90-modified-for-teens-spanish/ (Español)

Pediatric Health Specialists

Tuberculosis risk assessment form: Please complete before starting visit with your child’s healthcare provider.

http://3.12.152.62/pediatric-tb-risk-assessment-form/ (English)

Cuestionario: riesgo de tuberculosis: Favor de completar antes de empezar la visita con el proveedor de salud de su niño.

http://3.12.152.62/formulario-de-evaluacion-de-riesgo-de-tb-pediatrica/ (Español)

Pediatric Health Specialists

Lead risk assessment form: Please complete before starting visit with your child’s healthcare provider.

http://3.12.152.62/childhood-lead-risk-questionnaire/ (English)

Cuestionario: riesgo de contaminación de plomo: Favor de completar antes de empezar la visita con el proveedor de salud de su niño.

http://3.12.152.62/cuestionario-de-la-infancia-riesgo-de-plomo/ (Español)

Pediatric Health Specialists

Postpartum depression screening form: Please complete before starting visit with your child’s healthcare provider.

http://3.12.152.62/edinburgh-postnatal-depression-scale-epds-for-postpartum-depression/ (English)

Cuestionario: depresión en madres: Favor de completar antes de empezar la visita con el proveedor de salud de su niño.

http://3.12.152.62/escala-edinburgh-para-la-depresion-postnatal/(Español)

Pediatric Health Specialists

Authorization to disclose protected health information – Autorización para divulgar información de salud protegida

http://3.12.152.62/authorization-to-disclose-protected-health-information-autorizacion-para-divulgar-informacion-de-salud-protegida/ (Bilingual)

Pediatric Health Specialists

ImmTrac2, the Texas Immunization Registry Consent for Registration of Child and Release of Immunization Records to Authorized Entities

http://3.12.152.62/immtrac2-the-texas-immunization-registry-consent-for-registration-of-child-and-release-of-immunization-records-to-authorized-entities/ (Bilingual)

Pediatric Health Specialists

Request Form – Authorization to Disclose Protected Health Information – Autorización para divulgar información de salud protegida

http://3.12.152.62/request-form-authorization-to-disclose-protected-health-information-autorizacion-para-divulgar-informacion-de-salud-protegida/ (Bilingual)

Pediatric Health Specialists

Employee Complaint Form

 

Employee Action Form

Pediatric Health Specialists

COVID-19 Screening Questions

COVID-19 Screening Questions

Archived forms that are available online in public website:

Pediatric Health Specialists

Registration:

http://3.12.152.62/new-patient-registration/ (English)

Registro:

http://3.12.152.62/es/new-patient-registration/(Español)

Pediatric Health Specialists

NICU Developmental Follow Up Intake Form:

http://3.12.152.62/nicu-developmental-follow-up-intake-form/ (English)

Pre-registro: seguimiento después del NICU:

http://3.12.152.62/nicu-developmental-follow-up-intake-form-spenish/ (Español)

Pediatric Health Specialists

Check-in Form / Formulario de Registro:

http://3.12.152.62/check-in-form-formulario-de-registro/ (Bilingual)