Skip to content
FacebookTwitterInstagramYouTube

Call to Make an Appointment (714) 626-0074

Lander Chiropractic – Your Brea Chiropractor Logo Lander Chiropractic – Your Brea Chiropractor Logo Lander Chiropractic – Your Brea Chiropractor Logo
  • Home
  • COVID-19 Response
    • PreScreening Form
  • About
    • Meet the Doctors
    • Mission
    • Giving Back
  • Blog
  • Videos
    • Home Exercise Recommendations
    • Story Time With Dr. A
  • What We Do
    • Chiropractic Care
    • Chiropractic Care for Children
    • Sports Injuries
    • Pregnancy Care
    • Acupuncture
  • Contact

New Pediatric Patient Health History Form

Home/New Pediatric Patient Health History Form
New Pediatric Patient Health History FormKurt Abel2021-08-04T19:25:07+00:00

Step 1 of 8

12%

Patient Data

Patient Name(Required)
Date(Required)
Parent/Guardian Name(Required)
Your email will NOT be shared with any 3rd parties, and is used for occasional office announcements and promotions.
Has your child ever been treated by a chiropractor?(Required)

Mailing Address

Address(Required)
Date of Birth(Required)
Homeschooled?

Dietary Assessment - How Often Does Your Child Eat the following:

Beans, peas, lentils
Breads, cereals, grains
Candy
Dairy products
Eggs
Fruits
Meats
Poultry, fish
Sodas
Vegetables, green
Vegetables, orange
Vegetables, yellow

Medical History

Please check if child has ever had any of the following:
General
RESPIRATORY
NOSE/THROAT/CHEST
HEARING/SPEECH
CARDIOVASCULAR
GASTROINTESTINAL
EYES
DENTAL
MUSCLE/JOINT/BONE
GENITO-URINARY
SKIN

Has your child ever:

Broken bones?(Required)
Been hospitalized?(Required)
Had sprains/strains?(Required)
Been struck unconscious?(Required)
Had surgery?(Required)
Had diagnostic imaging (x-rays, MRI, ultrasound)(Required)

Family History

Additional Information

Has your child been vaccinated?(Required)
Does your child self adjust their neck or spine?(Required)
How often does your child self adjust?(Required)
Does your child participate in sports?(Required)
Consent(Required)
Please use your mouse or finger to sign in this box.

About Us

We want to empower you to take control of your health as it is our desire to assist you and your family in achieving optimum health, wellness, and longevity.

Lander Chiropractic

1203 Imperial Hwy #100
Brea, CA 92821
Phone: (714) 931-0475
Fax: (714) 582-1727

Main Office - Brea

Click to open a larger map

Office Hours

Monday - Saturday by appointment only. No walk-ins.

Our Services

Pages

  • Acupuncture
  • Bloom Attendee Raffle
  • Chiropractic Care
  • Chiropractic Care for Children
  • Chiropractic Care for Sports Injuries
  • Home Exercise Recommendations
  • New Acupuncture Patient Form
  • New Patient Form – Personal Injury
  • New Patient Form – Pregnancy
  • New Patient Health History Form
  • New Pediatric Patient Health History Form
  • Pregnancy Care
  • Safety & Support – Your Health & Concerns Matter To US: COVID-19 Response
  • Story Time With Dr. A

Connect With Us!

We are ICPA Certified

Copyright 2017 Lander Chiropractic | All Rights Reserved | Website by Two Cans Media
FacebookTwitterInstagramYouTube
Subscribe To The
Lander Letter
Get healthy recipes, health hacks, pregnancy and new mom tips, and be the first to know about our events and raffles.
Stay Updated
Give it a try, you can unsubscribe anytime.
close-link
Powered by Convert Plus
Go to Top