New Patient Intake - Children 12 and Under

Thank you for trusting us to help your child. We do not take this responsibility lightly. Your answers to these questions will tell us about your child's current health status and history of stress. Dr. Komeshak will review your answers in preparation for your first visit.

How Can We Help You?

Family History

Current Health Status

Health History

Stress is a contributing factor in all health conditions. There are 3 major categories of stress: physical (the things we do), emotional (the way we think), and chemical (the things we consume, absorb, and breathe). The following questions are designed to determine how these types of stress are affecting your child's health and life.

Have they ever:

Has your child ever suffered from:

Early Development

Lifestyle Habits

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