Pediatric Associates of Whidbey Island

275 SE Cabot Dr., Suite B-102

Oak Harbor, WA 98277

Phone: 360-675-5555

Fax: 360-675-0275

1690 Layton Rd.

Freeland, WA 98249

Phone: 360-331-1314

Fax: 360-331-9703

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Same Day Visit 13 years old & up

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

Name

Date of Birth

Tell us about what brings you in today?

Do you have:

Change in sleep?

Yes

No

Fatigue?

Yes

No

Change in appetite?

Yes

No

Red or draining eyes?

Yes

No

Ear Pain?

Yes

No

Sore Throat?

Yes

No

Congested or runny nose?

Yes

No

Cough?

Yes

No

Trouble breathing?

Yes

No

Vomiting?

Yes

No

Diarrhea?

Yes

No

Constipation?

Yes

No

Abdominal Pain?

Yes

No

Pain with urinating?

Yes

No

Pain in a joint or extremity?

Yes

No

Rash?

Yes

No

Headache?

Yes

No

Fever?

Yes

No

Vaginal or penile discharge?

Yes

No

First day of last menstrual cycle

NA

Have you had sex (oral, vaginal, anal)

Yes

No

Do you use condoms?

Always

Sometimes

Never

Have you had testing for sexually transmitted infections in the last 12 months?

Yes

No

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:

cell phone

home phone

other

Thanks for submitting!

Does your child :

275 SE Cabot Dr., Suite B-102

Oak Harbor, WA 98277

360-675-5555

1690 Layton Rd.

Freeland, WA 98249

360-331-1314

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