Same Day Visit 13 years old & up

This information will be kept private and not shared unless you give permission.

Do you have:

Change in sleep?
Fatigue?
Change in appetite?
Red or draining eyes?
Ear Pain?
Sore Throat?
Congested or runny nose?
Cough?
Trouble breathing?
Vomiting?
Diarrhea?
Constipation?
Abdominal Pain?
Pain with urinating?
Pain in a joint or extremity?
Rash?
Headache?
Fever?
Vaginal or penile discharge?
First day of last menstrual cycle
Have you had sex (oral, vaginal, anal)
Do you use condoms?
Have you had testing for sexually transmitted infections in the last 12 months?
If we need to talk to you privately after the visit, please give us the best way for us to get a hold of you:

275 SE Cabot Dr., Suite B-102 

Oak Harbor, WA 98277

360-675-5555

© 2020 Pediatric Associates of Whidbey Island  

1690 Layton Rd.

Freeland, WA 98249

360-331-1314