New Pediatric Patient Health History Form

Patient Data

Patient Name(Required)

First Last

Date(Required)

Parent/Guardian Name(Required)

First Last

Parent/Guardian Email(Required)

Your email will NOT be shared with any 3rd parties, and is used for occasional office announcements and promotions.

Primary Pediatrician's Name & Phone Number(Required)

Has your child ever been treated by a chiropractor?(Required)

Yes

No

When was your child last treated?(Required)

Mailing Address

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardian Cell Phone

Parent/Guardian Home Phone

Referred By

Age(Required)

Date of Birth(Required)

Number of Children in the Household(Required)

If you have multiple children, list the order of birth for your child.

Parent/Guardian Occupation(Required)

Parent/Guardian Employer

Marital Status(Required)

Emergency Contact(Required)

Emergency Contact Phone(Required)

Homeschooled?

Yes

No

Child's School

School City/State

Grade?

Family History

Please list any family members and any past or current health conditions (Example: heart disease, cancer, diabetes, arthritis, etc.) If none, please enter none.(Required)

Additional Information

Has your child been vaccinated?(Required)

yes

no

When was your child's first vaccination?(Required)

When was your child's last vaccination?(Required)

How many hours per night does your child sleep?(Required)

How many times a year does your child get sick?(Required)

How long do these episodes last?(Required)

Does your child self adjust their neck or spine?(Required)

Yes

No

How often does your child self adjust?(Required)

Daily

Infrequently

Does your child participate in sports?(Required)

Yes

No

Please list the types of sports and how often they practice per week:(Required)

Consent(Required)

Please check this box confirm that you have read and filled out all the information above. Please note: If you cannot make your appointment, please notify us within 24 BUSINESS hours. There is a $20.00 fee for any cancellation or rescheduled appointments less than 24 BUSINESS hours before your scheduled time or missed appointments.

Signature(Required)

Please use your mouse or finger to sign in this box.

Call to Make an Appointment (714) 626-0074

Patient Data

Mailing Address

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

Medical History

Has your child ever:

Family History

Additional Information

Lander Chiropractic