Pediatrics of Okaloosa
Click on the buttons to the right to open the form you need to print.
General Clinic Forms
*New to Clinic Patient Forms
1. New Patient Information Form
2. Medical Record Release Form
3. New Patient Health Questionnaire
4. HIPAA - Patients less than 18 years
5. HIPAA - Patients over 18 years
6. HIPAA Guidelines - Patients over 18 years
7. Consent for Treatment form without Parent or Legal Guardian
Flu Vaccine Screener - This screener is for ALL parents and ANYONE receiving flumist.
Teen Health Questionnaire:
Teen Questionnaires - for patients 13 years and older
Transition Questionnaire - for 16 years and older
PHQ-9 Depression Questionnaire - for patients 13 - 17
3040 - School Entry-Day Care health form<-- Click for form
* Please print form & complete page 1 prior to your office visit.
Bring both pages to your visit.
ADD - ADHD (Vanderbilt) Questionnaires
1. Initial Assessment - Parent
2. Initial Assessment - Teacher
3. Follow-up Assessment - Parent
4. Follow-up Assessment - Teacher
Controlled Substance Contract
American Academy of Pediatrics -
Well Child Visit Teaching Sheets