Chief Complaint Differential Diagnosis Checklist
Document and assess patient complaints with a structured differential diagnosis checklist.
Patient Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Chief Complaint
*
Onset and Duration of Chief Complaint
*
Associated Symptoms
Fever
Pain
Shortness of breath
Nausea/Vomiting
Cough
Other
Relevant Medical History
Risk Factors
Diabetes
Hypertension
Immunosuppression
Recent travel
Family history of relevant disease
Other
Physical Exam Findings
Differential Diagnosis Checklist
*
Rows
Considered
Ruled Out
Comments
Infection
1
2
Inflammatory
3
4
Malignancy
5
6
Trauma
7
8
Metabolic
9
10
Other
11
12
Urgency Assessment
*
Not urgent
1
2
3
4
Very urgent
5
1 is Not urgent, 5 is Very urgent
Clinical Impression / Most Likely Diagnosis
*
Recommended Next Steps
Further diagnostic tests
Specialist referral
Initiate treatment
Observation/follow-up
Other
Additional Notes
Submit Checklist
Should be Empty: