435 Highland Ave
Suite 110
Cheshire, CT 06410
View Location


Call us directly: 203-272-0396

Forms & Handouts

This section includes helpful forms and documents relevant to your child’s care. For you convenience, you can print out health forms and bring them to your visit already completed.

Check back regularly for further updates.

Well Child Schedule

Initial newborn visit

2 week visit 

1 month visit 

2 month visit

4 month visit

6 month visit

9 month visit

    • Ages and Stages Developmental Questionnaire

1 year old visit

    • Vaccines:  PCV13, MMR , Varicella (Chicken Pox)
    • Hemoglobin and Lead (screening tests for anemia and lead exposure)

15 month visit

    • Vaccines:  Hib, Hepatitis A
    • Ages and Stages Developmental Questionnaire

18 month visit

    • Vaccines:  DTaP
    • MCHAT – Autism screening tool to be filled out for all 18 month and 2 year old visits

2 year old visit

    • Vaccines:  Hepatitis A
    • MCHAT – Autism screening tool to be filled out for all 18 month and 2 year old visits
    • Hemoglobin and Lead (screening tests for anemia and lead exposure)

30 month old visit

    • Ages and Stages Developmental Questionnaire

3 year old visit

4 year old visit

5 year old visit

6 year old visit

7 year old visit

8 year old visit

9 year old visit

10 year old visit

11 year old visit

    • Vaccines:  TDaP,  HPV (Gardasil) series (Note: series can be given from age 11 to age 26)

12 year old visit

    • Vaccines:  MCV4 (Meningitis)

13 year old visit

    • PHQ-9: Teen Depression Screen

14 year old visit

    • PHQ-9: Teen Depression Screen
    • CRAFFT: Adolescent Substance Abuse Screen

15 year old visit

    • PHQ-9: Teen Depression Screen
    • CRAFFT (Adolescent substance abuse screen)

16 year old visit

    • PHQ-9: Teen Depression Screen
    • CRAFFT (Adolescent substance abuse screen)

17 year old visit

    • Vaccines:  MCV4 (Meningitis)
    • PHQ-9: Teen Depression Screen
    • CRAFFT (Adolescent substance abuse screen)

>18 year old visit

    • PHQ-9: Teen Depression Screen
    • CRAFFT (Adolescent substance abuse screen)

School Forms

Click on the links below to access a copy of the required school physical forms. If your child’s school or daycare requests that your pediatrician complete one of these forms, you can print it out at home and provide it to us after you have completed the parent part of the form. We will not print out a copy of this form for you.

Please allow 48 hours for forms to be completed.

Daycare/Pre-K

Kindergarten

Seventh Grade

Tenth Grade

Middle School/High School Sports

ADHD

The National Initiative for Children’s Healthcare Quality (NICHQ) has developed the ADHD Vanderbilt Assessment tools to assist pediatricians in diagnosing children with ADHD. A positive assessment is only the first step in the diagnosis of ADHD and should not be used as the sole criteria for diagnosis. If you have concerns about ADHD in your child, please consult with your child’s pediatrician prior to filling out these assessments.

Initial assessment tools

Follow up assessment tools