Child Pneumonia Risk Survey
Please complete this survey to help assess risk factors related to pneumonia in children. This screening is for informational purposes only and does not diagnose or treat any condition.
What is the child's age group?
*
Under 1 year
1-3 years
4-7 years
8-12 years
Has the child had a persistent cough in the past week?
*
Yes
No
Not sure
Has the child experienced difficulty breathing or rapid breathing recently?
*
Yes
No
Not sure
Has the child had a fever (100.4°F/38°C or higher) in the past week?
*
Yes
No
Not sure
Does the child have any chronic health conditions (e.g., asthma, heart disease)?
*
Yes
No
Not sure
Has the child received all recommended vaccinations for their age?
*
Yes
No
Not sure
Has the child recently been exposed to anyone with a respiratory infection?
*
Yes
No
Not sure
Does the child attend daycare, preschool, or school regularly?
*
Yes
No
Has the child been exposed to tobacco smoke or indoor air pollution at home?
*
Yes
No
Is there anything else you'd like to share about the child's recent health or symptoms?
Submit Survey
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