hereby authorize a member of the Wabash General Hospital medical staff and / or medical consultants to evaluate my child,

In the event that referral to a physician is necessary, the physician, consultant or certified athletic trainer is authorized to release medical and insurance information to that treating physician for purposes of treatment.

I release and hold harmless Wabash Hospital, its medical staff members, medical consultants and certified athletic trainers ("Wabash Staff") participating in the clinic from any and all claims, injuries, damages, losses or suits including attorney fees, arising out of or in connection with the participation in the clinic, except for injuries and damages caused by the sole negligence of the Wabash staff.

Note: Complete and sign this form (with your parents if younger than 18) before your appointment.

Patient Health Questionnaire Version 4 (PHQ-4) Over the last 2 weeks, how often have you been bothered by any of the following problems? 0 = Not at all, 1 = several days, 2 = over half the days, 3 = nearly every day

(A sum of ≥3 is considered positive on either subscale [questions 1 and 2, or questions 3 and 4] for screening purposes.)

I hereby state that, to the best of my knowledge, my answers to the questions on this form are complete and correct.

©2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educa- tional purposes with acknowledgment.