Pediatric Croup Assessment Form
Complete this form to assess the severity and symptoms of pediatric croup in a clinical setting.
Patient Full Name
*
First Name
Last Name
Patient Age (in months)
*
Parent or Guardian Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date and Time of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Barky cough present?
*
Yes
No
Stridor (noisy breathing) at rest?
*
None
With agitation only
At rest
Chest wall retractions observed?
*
None
Mild
Moderate
Severe
Respiratory Rate (breaths per minute)
Oxygen Saturation (%)
Additional Notes or Observations
Submit Assessment
Should be Empty: