Patient Forms

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Below are links to download all of our patient forms. Once downloaded, fill in and print out forms prior to your office visit to save time. If you prefer to fill out the forms in our office, please arrive at least 15 minutes prior to your appointment.

CarolinaEast Pediatric Forms

• Proxy Authorization
• Medical Records Release (Authorization for
  Release of Medical Records to CIM)
• Patient Acknowledgement and Consent
• New Patient Questionnaire
• Pediatric Psychiatry New Patient Questionnaire
• Authorization for Release
• Patient Registration, Beneficiary Agreement and Consent
• Authorization for Medical Care for Minors

Physical Forms

• Coastal Community Action, Inc. Children's Services Health Assessment Report (HEAD START)
• U.S. Marine Corps Children, Youth & Teen Programs (CYTP) Health Assessment
  (CHERRY POINT)
• North Carolina High School Athletic Association Sport Preparticipation Examination Form
• The Epiphany School of Global Studies Athletic Participation/Medical History
• The Epiphany School of Global Studies Student Health Inventory
• North Carolina Kindergarten Health Assessment Report
• Children's Medical Report (DAYCARE FORM)

Medicine Forms

• Craven County Schools Request for Medication to be Given During School Hours
• Arapahoe Charter School Authorization of Medication
• Child Care Inhaled Medication Form
• Beaufort Country Schools Authorization for Medication During School Hours
• The Epiphany School Asthma Management Plan
• The Epiphany School of Global Studies Prescription Medication Form
• Pitt County Schools Authorization for Medication
• Pamlico County Schools Authorization of Medication Form
• Lenoir County Public Schools Parent Request and Physician's Order for Medications to be
  given during School Hours
• Onslow County Schools Student Health Services Permission for Prescribed Medication to be
  given during School Hours

Anxiety Tools for Parent and Child

• Screen for Child Anxiety Related Disorders (SCARED) Parent Version
• Screen for Child Anxiety Related Disorders (SCARED) Child Version

Psychiatric Forms

• Patient Health Questionnaire-9 (PHQ-9)
• Dr. Evans Autism Tool
• Pediatric Symptom Checklist - Youth Report (Y-PSC)

Asthma Control Tests

• Asthma Control Test (ACT) for people 12 years and older.
• Asthma Control Test (ACT) for children 4 to 11 years.

Vanderbilt Forms

• NICHQ Vanderbilt Assessment Scale - Teacher
• NICHQ Vanderbilt Assessment Scale - Parent

MCHAT

• MCHAT

Ages & Stages Questionnaires

• Ages and Stages Questionnaire: 6 Months
• Ages and Stages Questionnaire: 12 Months
• Ages and Stages Questionnaire: 18 Months
• Ages and Stages Questionnaire: 36 Months
• Ages and Stages Questionnaire: 48 Months
• Ages and Stages Questionnaire: 60 Months