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Hassan H. Youssef, MD SC
400 South Kennedy Drive
Bradley, IL 60915

Tel:  +1 815-932-3132
Fax: +1 815-932-2397

dryoussefandstaff.com


 

Patient Forms

New patient before your first visit forms

We gladly welcome your family into our pediatric family! On this page are several documents you can print out and fill out prior to coming to your first appointment. Our Hippa policy does not have to be printed, but since you must sign that you have read the policy on the registration forms, it is provided for your convenience.

Records Release form

New Patient Questionnaire

Patient Information Sheet

Financial Policy / Missed Appointment Policy

 

HIPPA Forms:

Consensus for use and disclosure of health information

Request for Confidential Communications - need scan

Acknowledgement of received of Notice of Privacy Practice




Questionnaires

At various times, the doctor may ask you to complete a questionnaire to better assess a health concern or for routine screening purposes. The following are a list of questionnaires you may print out, complete and have ready at your next office visit.

ADD Forms:

  1. ADD Initial Evaluation Instructions

  2. ADD Attention Rating Scales

  3. ADD Diagnostic Criteria Form

  4. Comprehensive Behavioral Questionnaire

  5. ADD Health History Form


Depression Screening

Anxiety Screening

Oppositional Screening

Headache Questionnaire

 

Disclaimer 
All content on this website is intended for educational purposes and should not be used as medical advice for the treatment of illnesses or medical problems. In no way is this information intended as a substitute for individual professional medical care. If your child has a medical need, please contact our office for an appointment.

 
   
 


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