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

• State of CT Early Childhood Assessment Form

Kindergarten

• State of CT Health Assessment Form – required to enter kindergarten

Seventh Grade

• State of CT Health Assessment Form – required to enter seventh grade

Tenth Grade

• State of CT Health Assessment Form – required to enter tenth grade

Middle School/High School Sports

• State of CT Health Assessment Form – required yearly for middle school and high school sports participation

Medical Records Transfer Form (From Pediatric Associates)
Use this form to request your child’s medical records be transferred to another practice.

Request for Medical Records (into Pediatric Associates)
Use this form to have your child’s medical records transferred to our practice.

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:

• NICHQ Vanderbilt Assessment Scale—PARENT Informant (pdf)
• NICHQ Vanderbilt Assessment Scale—TEACHER Informant (pdf)

Initial newborn visit

2 week visit 

1 month visit 

2 month visit

• Vaccines:  Pediarix (DTaP, Polio, Hepatitis B),   Hib , PCV13,  Rotavirus

4 month visit

• Vaccines:  Pentacel (DTaP, Polio, Hib),  PCV13,  Rotavirus

6 month visit

• Vaccines: Pediarix (DTaP, Polio, Hepatitis B),  Hib , PCV13

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

• Vaccines:  MMR,  Varicella (Chicken Pox)

5 year old visit

• Vaccines:  Kinrix (DTaP/Polio)

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-2/9: Teen Depression Screen

14 year old visit

• PHQ-2/9: Teen Depression Screen
• CRAFFT: Adolescent Substance Abuse Screen

15 year old visit

• PHQ-2/9: Teen Depression Screen
• CRAFFT (Adolescent substance abuse screen)

16 year old visit

• PHQ-2/9: Teen Depression Screen
• CRAFFT (Adolescent substance abuse screen)

17 year old visit

• Vaccines:  MCV4 (Meningitis)
• PHQ-2/9: Teen Depression Screen
• CRAFFT (Adolescent substance abuse screen)

>18 year old visit

• PHQ-2/9: Teen Depression Screen
• CRAFFT (Adolescent substance abuse screen)

American Academy of Pediatrics

• www.aap.org
• www.healthychildren.org

Adolescent health

• www.girlshealth.gov
• www.youngwomenshealth.org
• www.youngmenshealthsite.org

ADHD

• www.nimh.nih.gov
• www.chadd.org

Car seat information

• www.ctsafekids.org

Immunizations

• www.cispimmunize.org
• www.immunize.org
• www.vaccinesafety.edu
• www.CDC.gov/vaccines

Learning disabilities/ developmental delay

• www.birth23.org
• www.aapd.com

Traveler’s Health and Preparedness

• www.cdc.gov/travel

If you have an urgent matter after hours, you can always call out main number (203)-272-0396 to reach an on-call provider. Our practice utilizes a nurse triage line after 7:00 pm.

These nurses are specifically trained in pediatric telephone triage. If need be, the nurse will contact the physician on call. If you do not hear back from them within 60 minutes, please call back.

If you need a prescription refilled, you can call our office and leave a detailed message on our prescription voicemail 24/7. Please allow at least 48 hours’ notice to complete your request.

Please note we do not refill prescriptions after the office has closed or on weekends.

Vaccination Policy