The following forms are for patients of UW Neighborhood Clinics. Please bring the completed visit or history forms with you to your appointment.
ADHD Forms
Adult Health History Form (PDF)
To be filled out by adult patients who are establishing care with a UW Neighborhood Clinics provider.
Anticoagulation Visit Form (PDF)
This form should be filled out by Coumadin patients prior to each anticoagulation visit.
Diabetes Questionnaire (PDF)
To be filled out by patients with diabetes prior to each diabetes visit.
Medicare - Initial Annual Wellness Visit Form (PDF)
To be completed by patients who have been eligible for Medicare for
more than 12 months.
Medicare - Subsequent Annual Wellness Visit Form (PDF)
To be completed by patients who have had their initial exam at least 365 days ago.
Medicare - Welcome To Medicare (PDF)
To be completed by patients who have been eligible for Medicare for
less than 12 months.
Medication History Form (PDF)
To be completed by new and established patients prior to an office visit.
Nutrition Questionnaire (PDF)
To be filled out by patients prior to their first visit with the Nutritionist.
Pediatric Well Visit Forms
To be filled out by the parent/guardian of the child prior to his/her Well Visit Appointment at the UW Neighborhood Clinics. Please select the appropriate form below.
Permission to Treat a Minor Without a Parent/Guardian Present (PDF)
To be filled out and signed by the parent/guardian of a minor patient if that patient will be seen without the parent/guardian present.
Prenatal History Form (PDF)
To be filled out by pregnant women who are establishing obstetrical care with a UW Neighborhood Clinics provider.
Preparing for Your Visit (PDF)
To be filled out by all patients to help you prepare for your upcoming visit.
Release of Information Forms >
Sports Physical Forms
Please refer to your school district's website for the appropriate Athletic Participation/Sports Physical forms.