LOMBARD - Pediatric New Patient Form (0-2 yrs)

1
Patient Full Legal Name* This field is required.
First Name
Middle Name
Last Name
2
Parent / Legal Guardian Full Name* This field is required.
First Name
Middle Name
Last Name
3
PATIENT Date of Birth* This field is required.
Year
Month
Day
4
PATIENT Age (months)* This field is required.
5
PATIENT Gender* This field is required.
Please Select
Please Select
Male
Female
N/A
6
Home Address:* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
United States
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Parent / Guardian Cell Phone Number:* This field is required.(or best number to contact you)
Area Code
Phone Number
8
E-Mail Address
9
Do you have an active insurance policy?* This field is required.
NO INSURANCE (SELF PAY)
BCBS HMO
BCBS PPO
CIGNA PPO
CIGNA HMO
AETNA PPO
AETNA HMO
UHC PPO
UHC HMO
MEDICARE
MEDICARE & SECONDARY
MEDICARE ADVANTAGE
MEDICAID
OTHER
10
If you have an active policy, what is the member ID? (skip if you provided your card to the front desk or if you have no insurance)
11
Who may we thank for referring you to our clinic?* This field is required.
12
Please type your previous Chiropractor's name and date of last visit (if applicable): * This field is required.
Type N/A if not applicable
13
Primary Concern(s) /Complaint(s):* This field is required.
Huge
Large
Normal
Small
Ok
Ok
14
Please select the health complaints your child is currently experiencing or has experienced in the past:* This field is required.Select ALL that apply.
NONE Applicable
Asthma
Allergies
Colic
Constipation
Diabetes
Ear Infection
Eczema
Feeding Problems
Food Allergies
Reflux
Scoliosis
Sinus Problems
Sleeping Problems
Torticollis/Plagiocephaly
15
Any additional information about the health of your child?* This field is required.Specify below or type no if not applicable.
Huge
Large
Normal
Small
Ok
Ok
16
Normal Pregnancy?* This field is required.
Yes
No
17
Any pregnancy complications?Describe below or click next.
18
Delivery type:* This field is required.
19
Any delivery complications?Describe below or click next.
20
Medications during delivery?Describe below or click next.
21
Infant Feeding Type:* This field is required.
Breast
Bottle
Formula
22
Problems with Nursing/Eating?* This field is required.Select ALL that apply.
NONE Applicable
Breast Preference
Constipation/Gas
Discolored Stools
Irritability
Latching Difficulty
Spitting up/Reflux
Tongue Tie
Other
23
What age did child: hold head up?* This field is required.
24
What age did child: crawl?* This field is required.
25
What age did child: sit?* This field is required.
26
What age did child: stand?* This field is required.
27
What age did child: walk?* This field is required.
28
Sleep Quality ?Describe any issue(s) below.
29
Hours of sleep each night ?Describe any issue(s) below.
30
Digestion ?Describe any issue(s) below.
31
Bowel Movements Per Day ?Describe any issue(s) below.
32
Immune Function ?Describe any issue(s) below.
33
Number of Ear Infections ?Describe any issue(s) below.
34
Immunizations Received ?* This field is required.
Yes
No
35
Please list any medications your child is currently taking: * This field is required.
Huge
Large
Normal
Small
Ok
Ok
36
Please list any traumas that your child has experienced below (falls, car accident, etc)* This field is required.
Huge
Large
Normal
Small
Ok
Ok
37
List immunizations received and age below.Separate each with a comma.
38
Any surgeries or congenital conditions?* This field is required.Separate each with a comma. Type N/A if not applicable.
39
Informed Consent for Chiropractic Care of a Minor* This field is required.Parent / Guardian of Patient Acknowledgment
40
HIPAA Practice Requirements* This field is required.Patient Acknowledgment
41
I hereby certify the statements & answers given on this form are accurate to the best of my knowledge. I am the parent or legal guardian of this patient and have read and fully understand the the above informed consent and hereby grant permission for my child to receive an evaluation and receive chiropractic care.* This field is required.
Clear
42
Today's Date* This field is required.
Date
Year
Month
Day
43
Tags
Todo
In Progress
Done
Should be Empty: