Street Medicine Check-in Form
For mobile care teams to record essential information during on-site visits with individuals experiencing homelessness or limited healthcare access.
Full Name (if known)
First Name
Last Name
Preferred Name or Alias
Date of Birth or Approximate Age
Gender Identity
Male
Female
Non-binary
Transgender
Prefer not to say
Other
Date and Time of Visit
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Visit (Street, Park, Shelter, etc.)
*
Current Needs (select all that apply)
Medical care
Wound care
Medication refill
Mental health support
Food/water
Hygiene supplies
Shelter/housing referral
Other
Main Symptoms or Health Concerns Today
Fever/chills
Cough/respiratory issues
Pain/injury
Skin issues/wounds
Mental health symptoms
Substance use concerns
No current symptoms
Other
Basic Screening (if performed)
Rows
Value
Temperature (°F or °C)
Pulse (bpm)
Blood pressure (mmHg)
Respiratory rate
Blood glucose (if checked)
Preferred Follow-up Contact Method
Phone call
Text message
Email
In-person outreach
No follow-up needed
Other
Best Way to Reach (if follow-up requested)
Provider Notes / Additional Information
Check In
Should be Empty: