Appendicitis Symptoms Assessment
Please complete this form to assess your symptoms. This assessment is informational and does not replace medical advice.
Full Name
*
First Name
Last Name
Age
*
Contact Email
example@example.com
How long have you been experiencing abdominal pain?
*
Please Select
Less than 6 hours
6-12 hours
12-24 hours
More than 24 hours
Where is your abdominal pain located?
*
Right lower abdomen
Around the navel (belly button)
Other area
Please rate the severity of your abdominal pain.
*
1
2
3
4
5
6
7
8
9
10
Which of the following symptoms are you currently experiencing? (Select all that apply)
*
Nausea
Vomiting
Fever
Loss of appetite
Constipation
Diarrhea
Abdominal swelling
Other
Please indicate how strongly you are experiencing the following symptoms:
*
Rows
Not at all
Mild
Moderate
Severe
Abdominal pain
1
2
3
4
Nausea
5
6
7
8
Vomiting
9
10
11
12
Fever
13
14
15
16
Loss of appetite
17
18
19
20
Have you noticed any of the following signs?
Pain increases when pressing and quickly releasing the lower right abdomen (rebound tenderness)
Pain worsens with movement, coughing, or walking
No such signs
Have you previously had similar symptoms or abdominal surgery?
Yes
No
Additional comments or information (optional)
Submit Assessment
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