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Pediatrics Forms

At Duly Health and Care, we want your appoint­ment to go as smooth­ly as pos­si­ble. Fill­ing out forms ahead of time helps us check your child in faster, so they can see their provider with­out delay

To help save time and ensure our care team has the infor­ma­tion need­ed to pro­vide high-qual­i­ty care, please com­plete all required forms before your appointment.

Forms accessed through the Duly web­site must be print­ed and com­plet­ed before your visit. 

Forms can also be com­plet­ed online through your MyChart account.

Login > Select your child’s pro­file (top right cor­ner) > Click the 3 lines on the top left cor­ner > Select ​“Ques­tion­naires”> Fill out forms

Forms can only be accessed on MyChart after an appoint­ment has been sched­uled. Cer­tain forms may take some time to pop­u­late on your account, so it is impor­tant to keep checking.

Infants (Birth — 12 months)

TB Screen­ing – 1 month old and 6 months old

The TB screen­ing ques­tion­naire is a tool used to assess an individual’s risk of tuber­cu­lo­sis infec­tion or dis­ease through ques­tions about symp­toms, expo­sure, med­ical his­to­ry, and high-risk factors.

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ASQ/SWYC Devel­op­men­tal Screen­ing – 9 months old

These forms are devel­op­men­tal and social-emo­tion­al screen­ing tools devel­oped to help iden­ti­fy whether young chil­dren are meet­ing key devel­op­men­tal mile­stones and whether fur­ther eval­u­a­tion may be needed.

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Tod­dlers & Ear­ly Child­hood (13 months – 5 years)

TB Screen­ing – All chil­dren annu­al­ly

The TB screen­ing ques­tion­naire is a tool used to assess an individual’s risk of tuber­cu­lo­sis infec­tion or dis­ease through ques­tions about symp­toms, expo­sure, med­ical his­to­ry, and high-risk factors.

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M‑CHAT – 18 months old & 24 months old

The M‑CHAT is a par­ent-report screen­ing tool that con­sists of ques­tions focused on a child’s behav­ior and devel­op­ment. It was devel­oped to help health­care providers iden­ti­fy ear­ly signs of cer­tain devel­op­men­tal concerns.

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ASQ/SWYC Devel­op­men­tal Screen­ing – 18 months old & 30 months old

These forms are devel­op­men­tal and social-emo­tion­al screen­ing tools devel­oped to help iden­ti­fy whether young chil­dren are meet­ing key devel­op­men­tal mile­stones and whether fur­ther eval­u­a­tion may be needed.

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Down­load 30 Month Form >

Lead Risk Ques­tion­naire – 3 years old through 6 years old

This form is used to iden­ti­fy chil­dren who may have been exposed to lead by deter­min­ing cer­tain risk factors.

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Child Health Exam­i­na­tion School Form – Pre‑K, Kinder­garten, & new-to-Illi­nois students

This form serves to offi­cial­ly doc­u­ment and autho­rize a child’s enroll­ment in a school dis­trict or day care set­ting. It shows the child is up to date on their well­ness plan and details if the child has cer­tain under­ly­ing med­ical con­di­tions the school or day­care should be made aware of.

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Chil­dren & Pre­teens – 6 years through 12 years (Grades K — 7th)

Lead Risk Ques­tion­naire – 6 years old

This form is used to iden­ti­fy chil­dren who may have been exposed to lead by deter­min­ing cer­tain risk factors.

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IHSEA Sport Form – Grades 5 through 7

This form is a stan­dard­ized med­ical and health screen­ing tool used to ensure stu­dent ath­letes are phys­i­cal­ly and med­ical­ly ready to par­tic­i­pate in sports. This form can be used for junior high grades and high school.

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Child Health Exam­i­na­tion School Form – Grade 6 & new-to-Illi­nois stu­dents

This form serves to offi­cial­ly doc­u­ment and autho­rize a child’s enroll­ment in a school dis­trict or day care set­ting. It shows the child is up to date on their well­ness plan and details if the child has cer­tain under­ly­ing med­ical con­di­tions the school or day­care should be made aware of.

Down­load Form >

TB Screen­ing – All chil­dren annually

The TB screen­ing ques­tion­naire is a tool used to assess an individual’s risk of tuber­cu­lo­sis infec­tion or dis­ease through ques­tions about symp­toms, expo­sure, med­ical his­to­ry, and high-risk factors.

Down­load Form >

Teens – 13 years through 18 years (Grades 8 – 12)

Child Health Exam­i­na­tion School Form – Grade 9 & new-to-Illi­nois stu­dents

This form serves to offi­cial­ly doc­u­ment and autho­rize a child’s enroll­ment in a school dis­trict or day care set­ting. It shows the child is up to date on their well­ness plan and details if the child has cer­tain under­ly­ing med­ical con­di­tions the school or day­care should be made aware of.

Down­load Form >

IHSEA Sport Form – Grades 8 through 12

This form is a stan­dard­ized med­ical and health screen­ing tool used to ensure stu­dent ath­letes are phys­i­cal­ly and med­ical­ly ready to par­tic­i­pate in sports. This form can be used for junior high grades and high school.

Down­load Form >

TB Screen­ing – All teens annually

The TB screen­ing ques­tion­naire is a tool used to assess an individual’s risk of tuber­cu­lo­sis infec­tion or dis­ease through ques­tions about symp­toms, expo­sure, med­ical his­to­ry, and high-risk factors.

Down­load Form >