Patient Resources

Forms

Below are forms that will need to be filled out prior to your first appointment with your Doctor. Please print and complete the information on each form as this can save you time during your office visit.


NICHQ Assessment Scale (Teacher) Form, NICHQ Assessment Scale (Parent) Form, Release of Medical History

 

Advice and Guidelines for Family
Handling an Emergency: Many parents are not sure what constitutes an emergency (when you need to call the doctor after the office is closed). We hope you find the following guidelines helpful. Please make sure you know which emergency room is covered by your insurance.
Go directly to the emergency room if your child:

  • has uncontrolled bleeding or a large laceration that needs to be sutured.
  • has an obvious severe fracture.
  • has a seizure that lasts longer than 10 minutes.
  • ingests a foreign substance. Please call poison control at 1-800-764-7661.

 

Definitely call us if your child:

  • is having severe pain not controlled with ibuprofen or acetaminophen.
  • has vomited more than three times in two hours and you do not have medication for vomiting (Phenergan, Tigan or Zofran suppositories). Call if vomiting is not controlled by medication.
  • is less than 2 months old with a fever of 100.4 degrees or higher.
  • is having difficulty breathing (except for a cold).

 

Please do not call at night or on weekends for:

  • Fever.
  • Cold symptoms. Coughs, stuffy or runny noses, matted eyes, sore throats, or ear rubbing are not emergencies. Please call during routine office hours. You may treat the symptoms with over-the-counter medicines until then.
  • Constipation. We will need to see your child to discuss cause and treatment.
  • Diarrhea. Feed your child normally and call during routine office hours for advice. Call if there is blood or severe cramping associated with the diarrhea.
  • Rash. Poison ivy, diaper rash, bug bites, eczema and other itchy entities should be seen and treated in the office. We cannot diagnose rashes over the phone. If the area itches or is swollen you may give oral Benadyl.
  • Ear pain. We do not prescribe antibiotics over the phone. Treat earaches with pain medication and call the office for an appointment.
  • Behavior problems. Eating, sleeping, potty training, school or any behavior problem, etc, will not be discussed over the phone. These need to be discussed in the office where you and your doctor can spend as much time as needed to answer your questions.
  • Prescriptions. Will only be refilled during routine office hours. Please do not call the triage nurse after hours or on weekends for prescription refills. She does not have access to your child’s medical record.

 

Well Child Check-up and Immunization Schedule
As part of our well child care, check-ups are given at regularly scheduled intervals, and vaccinations are an essential component of the care we provide our patients. The following calendar indicates the ages for routine check-ups and the vaccinations that are normally given at those checkups. Each check-up includes a growth and weight evaluation, a full developmental assessment and a complete physical examination.

Age at check-up . . . . . . . Immunizations/Screening Tests
Birth (in hospital). . . . . . .Hearing Screen, Newborn Screen (PKU), Hep B Vaccine
1st Week . . . . . . . . . . . . Post Hospital Exam/Weight check
4 Weeks*. . . . . . . . . . . . Growth evaluation, Review of Screening Tests, Hep B Vaccine
2 Months . . . . . . . . . . . . DTaP, Hib, IPV, Prevnar, Rotateq (oral)
4 Months . . . . . . . . . . . . DTaP, Hib, IPV, Prevnar, Rotateq (oral)
6 Months . . . . . . . . . . . . DTaP, Hib, IPV, Prevnar, Rotateq (oral)
9 Months . . . . . . . . . . . . Hep B Vaccine
12 Months*. . . . . . . . . . . Lead Screen, Hgb, MMR, Varivax, Prevnar
15 Months . . . . . . . . . . . DTaP, Hib, IPV
18 Months . . . . . . . . . . . Hgb (for patients at risk), Hep A Vaccine
2 Years . . . . . . . . . . . . . Hep A Vaccine
2-1/2 Years . . . . . . . . . . Cholesterol, Lead Screen
3 Years . . . . . . . . . . . . . Vision Screen (Cholesterol, Hgb, Tb screen for patients at risk)
4 Years*. . . . . . . . . . . . .Vision Screen, DTaP, IPV, MMR, Varivax, Hep A Vaccine (if needed)
5 Years . . . . . . . . . . . . . Hgb, U/A, Hearing & Vision Screens

* The 4 weeks, 12 months, and 4 years exams should NOT be done before these ages.

After 5 years, check-ups are recommended yearly. However, more frequent visits may be required for patients with developmental or psychosocial concerns or for chronic disease issues.

11-12 Years . . . . . . . . . . Tdap, Menactra, HPV (Gardasil), Hep A Vaccine (if needed), Varivax (if needed) 16-18 Years . . . . . . . . . . Menactra (if not previously vaccinated or if (16 years of age when received first dose)

 

Abbreviations Used Above:
DTaP . . . . . . . . . . . . . . . Diphtheria, Tetanus, acellular Pertussis (Whooping Cough)
Hep A. . . . . . . . . . . . . . . Hepatitis A Vaccine
Hep B. . . . . . . . . . . . . . . Hepatitis B Vaccine
Hgb . . . . . . . . . . . . . . . . Hemoglobin (test for Anemia)
Hib. . . . . . . . . . . . . . . . . Hemophilus influenzae, type b Vaccine
HPV . . . . . . . . . . . . . . . . Human Papillomavirus Vaccine (Gardasil)
IPV. . . . . . . . . . . . . . . . . Inactivated Polio Vaccine
Menactra. . . . . . . . . . . . . Meningococcal Vaccine
MMR . . . . . . . . . . . . . . . Measles, Mumps, Rubella Vaccine
Prevnar. . . . . . . . . . . . . . Pneumococcal Vaccine
Rotateq . . . . . . . . . . . . . Oral Rotavirus Vaccine
Tb . . . . . . . . . . . . . . . . . Tuberculosis
Tdap. . . . . . . . . . . . . . . . Tetanus, diphtheria, acellular pertussis (whooping cough)
U/A . . . . . . . . . . . . . . . . Urinalysis
Varivax. . . . . . . . . . . . . . Varicella (Chickenpox) Vaccine