Hello, and Welcome to Blueberry Pediatrics

Please complete the survey below for your child.

In the last two weeks, has your child:

had a Cough?

Yes
No

had a Sore Throat?

Yes
No

had a Runny Nose?

Yes
No

had a Fever?

Yes
No

Vomited?

Yes
No

had Diarrehea?

Yes
No

Thank You for your time, a nurse will be with you shortly

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