Pediatric Lyme Intake Form
Please complete this form to provide background and symptom information for pediatric Lyme assessment.
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent or Guardian Name
*
First Name
Last Name
Parent or Guardian Email
*
example@example.com
Parent or Guardian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Approximate Date Symptoms Began
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Has your child had any known tick bites in the past 12 months?
Yes
No
Not sure
Which symptoms has your child experienced? (Select all that apply)
Fever
Fatigue
Headache
Joint pain or swelling
Rash (including bullseye)
Muscle aches
Other
Has your child been diagnosed with Lyme disease before?
Yes
No
Current medications and allergies
Additional comments or concerns
Submit
Should be Empty: