Forms

Please click on the forms below that we have asked you to complete for your upcoming visit. 

Once you have completed the forms, you may print them and mail them to us or download the PDF and email it to us at documents@wrfpvt.com. This is a secure email and will protect your confidential medical information. Please include your name and date of birth in your e-mail. 

If you have any problems, please contact us at 802-295-6132.

 

Asthma Control Test Forms

• Children 4 to 11 years of age
• Children 12 to 17 years of age
• Adults

 

Ages & Stages Developmental Questionnaires

• 9 Months
• 18 Months
• 30 Months

 

Annual Wellness Questionnaire

These questions should be completed by Medicare patients and adults 65 and older prior to a yearly wellness exam 

 

Patient Health Questionnaire

This form should be completed by adults 64 years of age or younger prior to a yearly wellness exam, diabetes visit or asthma check-up

 

Screening for Anxiety

 

Social Needs Screening Tool

 

Attention-Deficit /Hyperactivity Disorder Questionnaires 

Parent

Teacher

 

Medical Release Form

New Patient Intake Form 

Hippa