Pediatric Screening Forms

Age-related screening forms for your child's well child office visit.
Please download the form, complete and bring with you to your well child's appointment.

• Newborn to 6 months: Risk Assessment Questionare
• 9 Months: ASQ-3 9 months
• 12 Months: Oral Health Assessment
• 18 Months: Oral Health Assessment, ASQ-3 18 months, M-Chat
• 24 Months: Oral Health Assessment, M-Chat
• 30 Months: Oral Health Assessment, ASQ-3 30 months
• 3-6 years: Oral Health Assessment
• 11-19 years: CRAFFT, PHQ-2, PHQ-9