Forms

History Forms

Wayzata Children's Clinic has created the following forms to obtain important information to better care for your child. By having you complete these questionnaires ahead of time, we can spend more time during the visit on questions important to you and your child.

For new families, please complete these forms prior to their first visit and bring them with you on the day of your child's exam. For existing families, you may complete these anytime but will be asked to complete them at the time of your child's well visit.

If you are unable to complete these forms ahead of time, they will be given to you at the time of the exam and will need to be completed that day.

• Patient History Questionnaire (once for each patient)
• Well Visit Questionnaire (once for each patient)
• Family History Questionnaire (once for the entire family)

Additional Forms

• Patient Information Form (for new patients only)
• Medical Records Release Form
• Health/Sports Physical Form
• ADHD Cardiac History Questionnaire (once for any patient being evaluated for or diagnosed with ADD/ADHD)

Operation Get Fit Forms

• Pre-program Questionnaire (for parents)
• Pre-program Questionnaire (for patients)