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

Same Day Visit less than 2 years old

Childs Name

Date of Birth

Tell us about your concerns today about your child.

Does your child :

Change in sleep?

Yes

No

If YES for how long?

Change in activity level?

Yes

No

Red or draining eyes?

Yes

No

Ear pain or pulling at ears?

Yes

No

Congested or runny nose?

Yes

No

Cough?

Yes

No

Trouble breathing?

Yes

No

Vomiting?

Yes

No

Diarrhea?

Yes

No

Constipation?

Yes

No

Change in urination?

Yes

No

Rash?

Yes

No

Fever?

Yes

No

Thanks for submitting!

275 SE Cabot Dr., Suite B-102

Oak Harbor, WA 98277

360-675-5555

1690 Layton Rd.

Freeland, WA 98249

360-331-1314

Designed by Marianne Borozny

with New Eve Creative