9423 Holy Cross Lane
St. Joseph's Hospital
Medical Arts Bldg One, Suite 111
Breese, IL 62230

1941 Frank Scott Parkway E
Suite A
Shiloh, IL 62269

Phone (618) 526-8850

View the KidsDoc Symptom Checker from HealthyChildren.org

Here are some PDF files or Word documents containing the forms that the parent or guardian of a new patient will be asked to complete upon establishing themselves as a patient at Right from the Start Pediatrics.

You will be asked to complete these prior to your first appointment, so using these links will save a great amount of time.

The policies to be acknowledged can be found by clicking the Office Policies button to the left.

We thank you in advance for your help!

  • Consent for Release of Records
  • Acknowledgment of Notice of Privacy Policies
  • Acknowledgement of Office Policies - obtain at first office visit
  • Adult Representative Consent Form 
  • Consent for Administration of Vaccines - This consent is to be reviewed and signed at the first office visit.  The vaccine schedule recommended by the Centers for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP) and the American Academy of Pediatrics (AAP) is followed.  Alternate schedules put children at risk for serious illness and as such, cannot be followed. Dr. Morra and his staff do not wish to put patients and the public at risk by allowing refusal or intentional delay of vaccination. We are passionate about the need for vaccinating children, including your children and our own. Trust is a very important part of the physician-patient-parent relationship.  Unfortunately, not trusting a pediatrician or nurse practitioner about the effectiveness and safety of vaccination may lead to lack of trust regarding other aspects of pediatric care. We do not wish to put you or us in that position. If vaccination is in no way agreeable to you, please call the office and we can find another local provider who might be able to accommodate your wishes for your child's care. If you do not wish to refuse vaccination, but simply want more education about the vaccines - what they do, when they are given, how the schedule is determined, etc. - please feel free to make an appointment and one of us can discuss this with you. Thank you in advance for your understanding in this matter.

Health History Form - *now "fill-able" this PDF file requires Adobe Acrobat 9.0 or higher- free download here.  You may fill in this form on your computer, then print it and bring it in. Or you may print it and fill it in by hand. We do require a hand-written signature on the bottom.

These are some forms that we ask you to complete at different well child visits.

Completing these forms adds a lot of information about a child's mother and the growth and development of the child as time passes.  Some of these are from the "Addressing Mental Health Concerns in Primary Care" CD that I purchased from the American Academy of Pediatrics and I would like to give the Academy credit here for providing this valuable resource to me.

Edinburgh Postpartum Depression questionnaire- We ask each new mother to complete this questionnaire at each well child visit until their child is one year old.  Research has shown that asking mothers about anxiety and depression several times through the first year can better identify mothers who are suffering from or at risk for postpartum anxiety or depression.  The pediatrician can work closely with a mother and her obstetrician to help manage these problems should they arise, and the best way to identify them is by asking.  Click the following link for a fill-able version of this questionnaire (password protected - need to be established patient to obtain password):

Edinburgh Postpartum Depression scale (disregard the second page - it is a scoring sheet   for office use only - thanks!)

Ages and Stages Questionnaires (ASQ) - developmental questionnaires that I provide to parents to complete prior to several critical well child visits.  These ages here are provided to all patients, but other ages can be completed if there are any questions at other ages.  Click the following links for fill-able versions of the ASQ (password protected - need to be established patient to obtain password):