Community Medical Group - Breathe. Live. Enjoy.

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Does your child frequently experience
coughing, particularly at night or early
morning?

YES

Question 2

Has your child had recurrent episodes
of wheezing or difficulty breathing,
especially during or after physical
activity?

YES

Question 3

Does your child have a history of
respiratory infections or episodes of
bronchiolitis, reactive airway disease,
or pneumonia?

YES

Question 4

Do you notice that your child’s
breathing worsens when exposed to
triggers such as allergens (e.g., pollen,
pet dander), smoke, or strong odors?

YES

Question 5

Has your child ever been diagnosed with
asthma or received any of the following
treatments (e.g., Albuterol, Prednisone,
Budesonide, and Montelukast)?

YES

We're almost done...

FIRST NAME

LAST NAME

CHILD'S NAME

AGE

ADDRESS

CITY

STATE

ZIP CODE

TELEPHONE NUMBER

EMAIL ADDRESS

WHEN SHOULD WE TALK?

Finally, do you have any questions or additional information you’d like to share with us?

LET'S CONNECT

Great! We are all done!

You’ve initiated an essential step in
prioritizing your child’s respiratory health.

You’ve initiated an essential step
in prioritizing your child’s
respiratory health.

A member of our team will reach out to you within
the next 24 hours to arrange an appointment.

A member of our team will reach out
to you within the next 24 hours
to arrange an appointment.

Thank you!

That's great!

We’re glad to hear that you’re not
experiencing any symptoms at the
moment. Your health and well-being
are important to us. Should you
experience any symptoms in the
future or have any questions, please
don’t hesitate to contact us.

We’re glad to hear that you’re
not experiencing any symptoms
at the moment. Your health and
well-being are important to us.
Should you experience any symptoms
in the future or have any questions,
please don’t hesitate to contact us.

We’re here to support you every
step of the way.

Stay well.

These questions serve as a targeted screening tool designed to ascertain whether you might be susceptible to asthma or currently experiencing symptoms associated with asthma or allergies. Responding “Yes” to any of these inquiries will prompt a consultation with our pediatricians for further assessment and preventive measures to mitigate potential complications.