* Today's Date:

Please use the following format MM/DD/YYYY
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* Which Provider was your appointment with:

* Child's Date of Birth

Enter in the following format MM/DD/YYYY
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* Patient Gender

* How difficult is it to take care of your child’s illness?

* How would you measure the level of stress level when caring for your child?
Please pick a number from “0” to “5” where “0” represents very low stress and “5” is for extremely high stress.

* Does your child’s doctor or office staff help to alleviate this stress
(e.g. with services, supports, or referrals, prescriptions and refills)?

* In the past 3 months, how many days have you or anyone in your family had
to stay home from work because of your child’s illness?

* Please rate the office where your child receives care for how they provide each of the following qualities? Please choose one option on each line.

* Getting an appointment when your child needs to be seen?

* Does your child's practice provide clear directions for who to contact or where to go for assistance when your child is ill.

* Office staff helped me to connect with family support organizations and
services in your community. (e.g. health insurance, support services, etc.)

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