Hyponatremia Symptom and Intake Assessment Form
Use this form to report current symptoms and recent intake details for a hyponatremia assessment.
Patient Information and Assessment Context
Full Name
*
First Name
Middle Name
Last Name
Age
Sex / Gender
Please Select
Female
Male
Intersex
Non-binary
Prefer not to say
Other
Assessment Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Reason for Assessment / Referral Context
Hyponatremia Symptom Review
Which symptoms have you experienced recently?
*
Overall symptom severity over the past 24 hours
*
No symptoms
1
2
3
4
5
6
7
8
9
Severe symptoms
10
1 is No symptoms, 10 is Severe symptoms
How severe has each symptom been over the past 24 hours?
Rows
None
Mild
Moderate
Severe
Headache
1
2
3
4
Nausea or vomiting
5
6
7
8
Confusion
9
10
11
12
Dizziness
13
14
15
16
Weakness or fatigue
17
18
19
20
Muscle cramps
21
22
23
24
Seizures
25
26
27
28
Reduced consciousness
29
30
31
32
Recent Intake and Fluid Exposure
In the past 24 hours, have you had unusually high fluid intake?
*
No
Yes
Which fluids have you consumed in the past 24 hours?
Water
Sports drinks
Tea or coffee
Juice
Soda
Alcohol
Broth or soup
Oral rehydration solution
Other
In the past 48 hours, have you received IV fluids?
No
Yes
Not sure
Submit Assessment
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