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Well Care Check-up Screenings

These forms should be completed when instructed by your Primary Care Provider (PCP).

Patient Health Questionnaire-2 (PHQ-2)

The postpartum period can be difficult for some parents. Your health is important for the health of your baby. The Pediatric Health Questionnaire-2 (PHQ-2) helps us screen for postpartum depression so that we can offer support if there are concerns. This short assessment is best completed by the patient’s biological mother, when available.

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M-CHAT-R

The M-CHAT-R is a developmental screening tool for toddlers at their 18- and 24-month well check appointments. It is designed to identify children who may benefit from a more thorough developmental evaluation.

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Pediatric Symptom Checklist-17 (PSC-17)

The Pediatric Symptom Checklist-17 (PSC-17) is a screening tool used to identify potential behavioral health concerns in children. Allegro providers use this routinely at all 6- through 11-year-old Well Child Check-ups.

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Patient Health Questionnaire-9 (PHQ-9)

The Pediatric Health Questionnaire-9 (PHQ-9) is a screening tool used at all Well Child Check-ups for children 12 years and older to identify concerns with depression. The patient should answer these questions, but the parent/guardian may help as needed.

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Confidentiality

Washington State has special protection for patient confidentiality starting at the age of 13. Your provider would like to take this Well Child Check-up as an opportunity to demonstrate Allegro Pediatrics as a safe place for your teenager to talk about anything they feel is important to their health and to encourage more independence for their own health care. If you and your teen feel comfortable, we invite your teen to fill out these forms confidentially and at the appointment, your provider will review the forms with your teen.

Patient Health Questionnaire-9 (PHQ-9)

13-year-old and above Well Child Check-up form.

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Teen Questionnaire

13-year-old and above Well Child Check-up form.

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Authorization to Leave Patient Health Information by Alternate Means

The Authorization to Leave Patient Health Information by Alternate Means allows patients starting at the age of 13 to be contacted directly about test results. It also allows patients to designate which if any, parents/caregivers can receive certain health information.

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