Patient Forms
Below, you will find commonly needed forms. Please complete all the information that you can (such as name, birthdate, and address) BEFORE submitting to us for completion.
Completed forms will be returned to you via fax. Alternatively, you may provide a self-addressed, stamped envelope for mail return to you or directly to the school. You may also arrange for in-person pickup once the form is complete.
Routine forms brought to your child’s check-up will be completed at no charge. However, a $20 fee applies to routine forms submitted during a sick visit or between scheduled appointments.
Required School Forms
Medical Forms for School
Forms for Tracking Medical Issues
Required School Forms
Delaware Daycare Form
If your child attends a licensed day care in Delaware, you must fill out the top portion of this form and give it to us to complete.
Delaware School Form: K-6th grade
This is the school physical form for entry into Delaware elementary schools.
Delaware School Form: 7th-12th grade
This is the school physical form for entry into Delaware junior high and high schools.
DIAA Athletic Form
Delaware schools must collect a doctor’s form for each high school student involved in school sports. Please fill in as much information as possible (such as the child’s name, address, etc.) before bringing it to us for signing. (This form is updated for 2016 and after.)
Medical Forms for School
ADHD Vanderbilt Rating Scale (Parent)
Rating scales are sometimes used to evaluate for ADHD. Here are scales developed by the AAP and Vanderbilt University.
ADHD Vanderbilt Rating Scale (Teacher)
Rating scales are sometimes used to evaluate for ADHD. Here are scales developed by the AAP and Vanderbilt University.
Asthma Action Plan
Asthma “action plans” are sometimes required by school nurses, so that they have instructions when a child starts wheezing. These forms must be signed by the doctor or nurse practitioner.
PPD Fax-Back Form
A skin test for Tuberculosis (PPD) is required for all new school entrants. The skin test must be checked 48-72 hours after we plant it. If the school RN is willing to check the reaction, please ask her to complete and fax this form to us.
Forms for Tracking Medical Issues
Asthma Peak Flow tracking chart
Asthmatic children can benefit by keeping track of Peak Flow Meter readings over time. You may want to print this form and show us the data you collect.
Calorie Count Spreadsheet
If you worry that your child doesn’t eat enough, here’s a sheet to count calories.