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WASHINGTON UNIVERSITY CLINICAL ASSOCIATES

Premier Pediatrics

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Patient Forms

Patient Forms

New Patients (please print, complete and bring to your child’s first appointment).

  • Premier Pediatrics Patient Form – PDF
  • Patient Communication Form – PDF
  • Ages and Stages Questionnaire – Child development screening: Please complete no more than one week before your child’s appointment. Print out the completed copy and bring this to the scheduled appointment.
  • Request A Copy of Your Medical Records (for yourself) – PDF
  • Request Medical Records Release (to a third party) – PDF

Other Forms

  • ADHD Questionnaire – NICHQ Vanderbilt Assessment Scales – PDF
  • Depression Questionnaire – PHQ-9 – PDF
  • Screen for Child Anxiety Related Disorders (SCARED) – For child to complete – PDF
  • Screen for Child Anxiety Related Disorders (SCARED) – For parent to complete – PDF
  • Autism Questionnaire – Modified Checklist for Autism in Toddlers, Revised, with Follow-up (M-CHAT-R/F) – PDF
  • Postnatal Depression Questionnaire – Edinburgh Scale – PDF
  • Patient Information
    • Patient Forms
    • ADHD Medication Refills
    • Resources

Premier Pediatrics

Washington University Clinical Associates (WUCA)

150 Richardson Crossing

Arnold, MO 63010

314-859-4000

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