All forms require Adobe Acrobat Reader. Please Note: There is a 48 hour turn around on all forms needing completion by a health care provider. All Parent portions must be completed before being submitted to the office.
Questionnaires in English:
- Lead screening evaluation
- TB screen evaluation
- Lead and TB screening evaluation
- M-CHAT questionnaire
- Pediatric Symptoms Checklist (6-11)
- Pediatric Symptoms Checklist - Y (12-20)
- 405 Request for Self-Administration of Medications
- TSSAA Participation Form Please Note: The Health History page and the questions under #1 on the Physical Exam page must be completed before Plateau Pediatrics will complete the providers portion. All questions on the Health History Page that received an answer of "yes" must be explained at the bottom.
Questionnaires in Spanish:
- Investigaciόn para el plomo
- Investigación para tuberculosis (TB)
- Investigaciόn para el plomo y tuberculosis (TB)
- Cuestionario del desarrollo comunicativo y social en la infancia (M-CHAT/ES)
- Estudio sobre adaptacion social y emocional de los ninos (PSC)