Insect Bite Physical Exam Documentation Form
Document patient information and physical exam findings following an insect bite.
Patient Full Name
*
First Name
Last Name
Date of Examination
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Suspected Insect Type
*
Please Select
Mosquito
Bee/Wasps
Ant
Spider
Tick
Unknown
Other
Date and Time of Bite
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Bite on Body
*
Initial Symptoms Experienced
*
Redness
Swelling
Pain/Tenderness
Itching
Blistering
Rash
Other
Physical Exam Findings
*
Rows
Present
Not Present
Redness
1
2
Swelling
3
4
Warmth
5
6
Induration
7
8
Discharge
9
10
Ulceration
11
12
Lymphangitis
13
14
Systemic Symptoms
Fever
Chills
Fatigue
Nausea/Vomiting
Shortness of Breath
None
Other
Known Allergies (including insect stings)
Treatment Administered or Recommended
Provider Notes / Additional Observations
Submit Documentation
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