Tonsil Assessment Form
Complete this form to document patient tonsil health, symptoms, and clinical findings for evaluation.
Patient Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Age
*
Presenting Symptoms (Check all that apply)
*
Sore throat
Fever
Difficulty swallowing
Ear pain
Bad breath
Swollen glands
Other
Duration of Symptoms (in days)
*
Tonsil Examination Findings
*
Rows
Normal
Enlarged
Erythema
Exudate
Asymmetry
Right Tonsil
1
2
3
4
5
Left Tonsil
6
7
8
9
10
Tonsil Size (Grade)
*
Grade 0 (No enlargement)
Grade 1 (≤25% of oropharyngeal width)
Grade 2 (26-50%)
Grade 3 (51-75%)
Grade 4 (>75%)
Severity of Sore Throat (1 = Mild, 5 = Severe)
*
Mild
1
2
3
4
Severe
5
1 is Mild, 5 is Severe
Relevant Medical History
Recent upper respiratory infection
Frequent tonsillitis
Allergies
Immunocompromised
Other
Clinical Notes / Additional Observations
Provider Name
*
First Name
Last Name
Submit Assessment
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