New Patient Questionnaire for Little Flower Pediatrics

Thank you for considering Little Flower Pediatrics for your child's healthcare needs!

As we grow and search for an additional pediatrician to join our practice, it is important for us to better understand your family’s preferences to ensure we can provide the best care possible. Please take a few moments to answer the following questions.

General Information

Parent/ Guardian Names *

Phone Number *

Email Address *

How many kids under 18 live in your household?

1
2
3
4
5
6 or more
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Ages of children to be enrolled:

Age of Child 1:

Age of Child 2:

Age of Child 3:

Age of Child 4:

Age of Child 5:

Age of Child 6:

Age of Child 7:

Healthcare Philosophy and Preferences

How important is integrative medicine (a combination of conventional and alternative treatments) in your choice of pediatrician?

Very important

Somewhat important

Not important

Do you prefer a pediatrician who incorporates holistic or natural approaches into care (e.g., nutrition counseling, acupuncture, chiropractic care)?

Yes

Undecided or Not Important to Me

Vaccination Preferences

Will your child/children be receiving vaccines?

Yes

Undecided

If yes, will you follow the American Academy of Pediatrics (AAP) vaccination guidelines?

Yes

No. I would like to follow an alternate schedule, giving all vaccines eventually.

No. I plan on giving some, but not all the routine vaccines

Undecided

Parenting & Childcare Preferences

What are your top priorities in your child’s healthcare? (Check all that apply)

Preventative Care (e.g., wellness checks, screenings)

Treatment of Acute Illnesses (e.g., colds, infections)

Chronic Condition Management (e.g., asthma, allergies)

Mental Health Support (e.g., anxiety, depression)

Developmental/Behavioral Support (e.g., ADHD, autism spectrum)

Nutrition and Healthy Lifestyle Counseling

Other

Please specify

Do you prefer to have in-person or virtual visits for follow-up care?

In-person

Virtual

No preference

Are there any health conditions or family medical history you would like us to be aware of in caring for your child/children?

Yes

Please specify if your answer is "Yes"