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Maryland Healthy Kids Provider Forms

The listed provider forms are recommended/required for use of the providers when doing preventive visits per Healthy Kids Program guidelines. To open a document, click on the "X" sign.

 

  
  
  
  
Medical Family History Questionnaire (English)X2017
Medical Family History Questionnaire (Spanish)X2017
Mental Health Questionnairies (English)XX2014
Mental Health Questionnairies (Spanish)XX2014
Preventative Screen Questionnaire (English)X2017
Preventative Screen Questionnaire (Spanish)X2017
CRAFFT Adolescent Substance Abuse Assessment (English)X2014
CRAFFT Adolescent Substance Abuse Assessment (Spanish)X2014
Nutrition QuestionnairesX2014
Encounter FormsXX2014
Child Abuse Assessment: SEEK Questionnaire (English)X2014
Child Abuse Assessment: SEEK Questionnaire (Spanish)X2014
Patient Health Questionnaire Modified for Teens (PSC-Y)X2014
Pediatric Symptoms Checklist for Teens (PHQ-9)X2014
WHO and CDC Growth ChartsX2014
Objective Hearing and Vision Testing FormsX2015
Victimization Scale (English)X2015
Victimization Scale (Spanish)X2015
School-Based Health Centers Health Visit Report FormX2015
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