Patient Forms

We know your hands are full when you get to the office.  Feel free to print some of your forms at home and bring them with you to your visit

General visit forms

  • M-CHAT-R (Modified Checklist for Autism in Toddlers) : 18 month visit and 2 year visit only
  • Patient Screening Questions : Newborn visit, 1 year visit, 2 year visit, and all visits starting 3 years and after
  • IHSA Pre-participation Examination (Illinois sports form): Parent/athlete should fill out pages 2-4 [Online] [PDF]

New patients

Authorization for Release of Records: Please have your medical records faxed to us ahead of your appointment (312-943-6924).  You can print this form and send it to your previous doctor.

Notice of Privacy Practices

 We can fill out camp and school forms as long as your child has had a well visit in the last 12 months.  Please allow up to 5 business days to recieve completed forms.  You may also bring your printed forms with to your next scheduled appointment.  Give them to the nurse at the beginning of the visit and we will try to finish them before you leave.

In order to view or print these forms you will need Adobe Acrobat Reader installed.
Click here to download it.

Our Location

1030 N Clark Street, Suite 400 Chicago, IL 60610

Hours of Operation

We are now accepting walk-ins Monday - Saturday from 8:30 - 11:30am! Telemedicine appointments are still offered based on availability.

Child & Adolescent Health Associates


8:30 am-5:00 pm


8:30 am-7:30 pm


8:30 am-5:00 pm


8:30 am-7:30 pm


8:30 am-5:00 pm


8:30 am-11:30 am