Forms and Questionnaires
On this page you will find links to various forms that may be
required for your appointment with the Paediatrician.
These forms can be filled out in advance of your appointment and
faxed to our office (250-754-1211) or dropped off (see the home page for our location)
Consent Form
The Consent Form is filled out by a parent or legal guardian to authorize another doctor, a school, the Child Development Centre, or another professional or organization to release information about your child to the Paediatrician. The form allows you to specify what information is to be shared and for what time period. It is not required if you provide a copy of your copy of any reports you have.
SNAP-IV
The Swanson Nolan and Pelham Rating Scale Revised (SNAP-IV) is filled out by your child's teacher and at least one parent. It can be filled out by anyone who spends a significant amount of time with your child, such as an Educational Assistant, grandparents, other caregivers, and the patient. It is a screening questionnaire to help identify problems such as attention difficulties, anxiety, or learning difficulties that can impair your child's developmental, academic, and social progress.
NICHQ Vanderbilt Assessment Scales
NICHQ Vanderbilt Assessment Scales
The American National Institute for Children's Health Quality Vanderbilt Assessment Scales are similar to the SNAP-IV and are used to help diagnose ADHD in children between ages 6 and 12. It is filled out by your child's teacher or teachers and one or both parents.
WFIR-S
The Weiss Functional Impairment Rating Scale Self-administred is filled out by the child or the parents. It is a rating scale to assess how a child is doing with their activities of daily living.
SCARED
The Screen for Child Anxiety Related Disorders is filled out by the child and the parents. It is a screening questionnaire to help identify symptoms of anxiety that can impair your child's developmental, academic, and social progress.
PHQ-9
The Patient Health Questionnaire is filled out by the child. It is a screening tool to assess for symptoms of depression.
AQ-10
The Autism Quotient is filled out by the parent or child. It is a screening tool to assess for typical features of Autism Spectrum Disorder.
Electronic Forms
Disability Tax Credit Certificate. Read the guide on the page for understanding who the tax credit is for and how to apply. I recommend using the new digital form.
Student Aid BC Appendix 8. For applying for accomodations and financial assistance in post secondary education if you have a permanent disability.
Fair PharmaCare. Apply for Fair PharmaCare for financial support to pay for many prescription drugs and some medical devices and supplies.
Medical Services Plan. Information on how to register for the plan that pays for medically required physician and surgeon services.
Can't Complete the Form?
Fill in the form or questionnaire to the best of your ability. Our office staff and your Paediatrician can help you with items you are uncertain about.