Pediatric 6-12 New Patient Form

Reason for Visit:

Describe the reason for this visit:*
Please select at least one option
Is the purpose of this appointment related to:*
Please select at least one option
Did this condition start:
Is this problem:
Has this condition:
Does this condition interfere with:
Has this condition occurred before:

General Health History:

Does your child eat well?
Are you aware of the impact nutrition can have on your child’s behavior?
Would you like more information about nutrition for your child?
Does your child have daily bowel movements?
Does your child sleep well?
Does your child sleep on his/her

Growth and Development:

Does your child have developmental or developmotor delays?
Has your child ever been hospitalized?
The National Safety Council reports approx. 50% of children fall head first from a high place during their first year of life (i.e. bed, changing table, stairs, etc.) Was this the case for your child?
Has your child ever been in a car accident?
Has your child ever had surgery?
Does your child have difficulty interacting with others?
Have you or anyone else noticed that your child is nervous, twitches, shakes or exhibits rocking behavior?
Was it?
Does your child attend school/preschool?
Does your child carry a backpack?
Are there any smokers living in the home?
Are there any indoor pets in your home?

Review of Systems:

Please mark all conditions/symptoms your child has experienced:

Thank you for taking the time to fill out this form.

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Office Hours

Our Regular Schedule

Lancaster (Historic Downtown)


8:00 am-5:00 pm


7:00 am-4:00 pm


8:00 am-5:00 pm


7:00 am-4:00 pm


6:00 am-1:00 pm