9. Pediatric Common Cases
1. Is your child currently experiencing any of the following?
(Select all that apply)
Fever
Persistent cough
Flu
Skin rash
Earache
Difficulty breathing
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2. How long has your child been unwell?
Less than 1 week
1–2 weeks
Over 2 weeks
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3. Has your child been exposed to sick individuals recently?
Yes
No
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4. Is your child taking any medications or supplements?
Yes
No
If yes, please specify
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5. Does your child have any known allergies or chronic conditions?
Yes
No
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First Name
Last Name
Email
Phone/Mobile
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