Patient Forms

We are also happy to offer you the option to download, print and complete forms to reduce wait times.
In order to view or print these forms you will need Adobe Acrobat Reader installed. Click here to download it.

New Patient Forms

Demographic Information for 17 years and younger
Demographic Information for 18 years and older
Notice of Privacy Practices and Patient Consent Form
Family History Form
Authorized Adults Form

Los Alamos Public Schools Forms

Sports Form
State of New Mexico Concussion Form and Information Sheet
Food Allergy Action Plan Sheet
LAPS School District Forms Link
Return to Athletic Participation
Kindergarten Health Examination by Physician
Permission Form for Administering Medication in Schools

ADHD Forms

Vanderbilt Parent Forms
Vanderbilt Parent Forms Follow Up
Vanderbilt Teacher Forms
Vanderbilt Teach Forms Follow Up

Asthma Forms

Asthma Action Plan
Asthma Control Test (12 and over)
Asthma Control Test (4 to 11)

Immunization Forms

Vaccine Information Forms
Vaccine Administration Form
Vaccine Information Form - Spanish

Other Forms

Adolescent Depression Form

Ages and Stages Questionnaires (English)

1-3 mo. ASQ3-Questions
3-5 mo.ASQ3-Questions
5-7 mo.ASQ3-Questions
7-9 mo.ASQ3-Questions
9-11 mo.ASQ3-Questions
11-13 mo.ASQ3-Questions
13-15 mo.ASQ3-Questions
15-17 mo.ASQ3-Questions
17-19 mo.ASQ3-Questions
19-21 mo.ASQ3-Questions
21-23 mo.ASQ3-Questions
23-25 mo.ASQ3-Questions
28-31 mo.ASQ3-Questions
35-39 mo.ASQ3-Questions
45-50 mo.ASQ3-Questions
57-66 mo.ASQ3-Questions

Ages and Stages Questionnaires (Español)

1-3 mo. ASQ3-Preguntas
3-5 mo. ASQ3-Preguntas
5-7 mo. ASQ3-Preguntas
9-11 mo.ASQ3-Preguntas
11-13 mo. ASQ3-Preguntas
15-17 mo.ASQ3-Preguntas
17-19 mo.ASQ3-Preguntas
28-31 mo.ASQ3-Preguntas
35-39 mo.ASQ3-Preguntas
45-50 mo.ASQ3-Preguntas
57-66 mo.ASQ3-Preguntas

Ages and Stages Activities Forms

1-4 mo. Activities for Infants
4-8 mo. Activities for Infants
8-12 mo. Activities for Infants
12-16 mo. Activities for Infants
16-20 mo. Activities for Toddlers
20-24 mo. Activities for Toddlers
24-30 mo. Activities for Children
30-36 mo. Activities for Children
36-48 mo. Activities for Children
48-60 mo Activities for Children
60-66 mo. Activities for Children