/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/questionnaires/,

/clinical/cckm-tools/content/questionnaires/name-117295-en.cckm

201706158

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Questionnaires

NICHQ Vanderbilt Assessment Follow-up - Teacher Informant (301815-DT)

NICHQ Vanderbilt Assessment Follow-up - Teacher Informant (301815-DT) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires



Patient Name

DOB:

MR #


UWH# 301815-DT (Rev. 03/17/16) Scan to Questionnaire – Health NICHQ VANDERBILT ASSESSMENT
FOLLOW-UP – TEACHER INFORMANT Page 1 of 2
University of Wisconsin Hospitals and Clinics
NICHQ VANDERBILT ASSESSMENT
FOLLOW-UP – TEACHER INFORMANT











Patient Name

DOB:

MR #


UWH# 301815-DT (Rev. 03/17/16) Scan to Questionnaire – Health NICHQ VANDERBILT ASSESSMENT
FOLLOW-UP – TEACHER INFORMANT Page 2 of 2
University of Wisconsin Hospitals and Clinics
NICHQ VANDERBILT ASSESSMENT
FOLLOW-UP – TEACHER INFORMANT






























Signature of Patient/Representative _________________________________Date: __________ Time: __________AM/PM


If signed by person other than the patient, print name and state relationship and authority to do so.


Print Name: _____________________________________Relationship: __________________________________

Patient is:  Minor  Incompetent / Incapacitated
Legal Authority:  Legal Guardian  Parent of Minor  Health Care Agent  Other _____________________


Reviewed by: ___________________________________________________ Date: ______________ Time: __________ AM/PM




For Office Use Only
Total Symptom Score for questions 1 – 18: ________________________ Average Performance Score: ____________________



Please return this form to: _____________________________________ Fax Number: ________________________________
Mailing Address: ______________________________________________________________________________________________
____________________________________________________________________________________________________________