Implantation Discharge Symptom Check Form
Use this form to report symptoms and concerns after your implantation discharge so the care team can review your condition and decide on follow-up.
Patient and Procedure Details
Patient Full Name
*
First Name
Middle Name
Last Name
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.
Discharge Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Implantation Procedure
*
Dental implant
Pacemaker implantation
Cochlear implant
Orthopedic implant
Breast implant
Other
Implant Location / Site
*
Please Select
Head/Neck
Chest
Arm
Leg
Jaw
Other
Follow-Up Date and Time of Symptom Check
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Current Symptom Check
Any new or worsening symptoms since discharge?
*
No
Yes
Which symptoms are you experiencing?
Pain
Swelling
Redness
Warmth
Bleeding
Discharge
Fever
Chills
Dizziness
Nausea
Shortness of breath
Chest discomfort
Rash
Numbness or tingling
Other procedure-related concern
When did the symptoms start?
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
How severe are the symptoms?
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Condition Details and Care Actions
Pain level
*
No pain
1
2
3
4
5
6
7
8
9
Worst pain
10
1 is No pain, 10 is Worst pain
Compared with discharge, symptoms are
*
Improving
Unchanged
Worsening
Have you taken any medication or used home care since discharge?
*
Yes
No
Medication or home care details
Does the incision or procedure site look abnormal compared with the discharge instructions?
*
Yes
No
Not sure
Have you contacted a clinician or urgent care already?
*
Yes
No
Additional observations or concerns
Follow-Up Status
Needs callback follow-up?
*
Yes
No
Preferred contact method
*
Please Select
Phone
Text
Email
Other
Best time to contact
Hour Minutes
AM
PM
AM/PM Option
Triage/disposition summary
Submit Symptom Check
Should be Empty: