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  • 5284 Lyngate Court, Burke, VA 22015

  • Mon-Thur: 8am-5pm / Fri: 8am-12pm

New Patient Medical History Form










Please mark YES if your child has a history of the following conditions. For each “YES”, provide details in the box at the bottom of this list. Mark NO after each line if none of those conditions applies to your child.




















































Does your child have a history of any of the following? For each YES response, please describe:






































How frequently does your child have the following?









(* such as juice, fruit-flavored drinks, sodas, colas, carbonated beverages, sweetened beverages, sports drinks, or energy drinks)