Primary Care, Coatesville

Health Form Requests

The following are guidelines when requesting a health form:

Forms for your visit

The following forms can be downloaded, printed, filled out and brought with you to your scheduled well visit if necessary. Be proactive: schedule annual well visits for your child.

Newborn or new patient

If you are bringing your newborn to our office for the first time, or if your child is a new patient at CHOP Primary Care, Coatesville, please download, print and fill out this registration form and bring it with you to your child's upcoming well-child visit.

Newborn and New Patient Registration Form

Health questionnaires

Choose the questionnaire that matches the sex and age of your child. Download, print and fill out the form and bring it with you to your child's upcoming well-child visit. 

Female Adolescent Questionnaire (12-15 years)

Older Female Adolescent Questionnaire (16-17 years)

Male Adolescent Questionnaire (12-15 years)

Male Older Adolescent Questionnaire (16-17 years)

Nutrition questionnaires

Choose the questionnaire that matches the age of your child. Download, print and fill out the form and bring it to your child's upcoming well-child visit.

Nutrition Questionnaire (2-11 years)

Nutrition Questionnaire (12 and over)

Parent/Guardian Questionnaire: Guidelines for Adolescent Preventive Services

Parents and guardians who bring a chlid to the office for a well visit should download, print, and fill out the following form before their appointment.

Parent/Guardian Questionnaire

Other health forms

Interim Health Form

Sometimes we receive forms that ask whether a patient can safely do certain kinds of work, participate in organized camps, sports, drive a vehicle and so on. A comprehensive annual check-up is the best way to determine eligibility for such activities. Even if the patient has had a check-up within the past year, there may be a long interval between the physical exam and the time the form has to be filled out. For these situations, if more than three months has elapsed since the last check-up, we request that the patient or parent complete the following questionnaire. Bring the completed form to the office with your payment.

Interim Health Form

Modified Checklist for Autism in Toddlers (M-CHAT)

The M-CHAT is validated for screening toddlers between 16 and 30 months of age, to assess risk for autism spectrum disorders (ASD). 

M-CHAT (form is on page 2)

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