Pediatric Pharyngitis Assessment Form
Please complete this form to assist in evaluating your child's sore throat symptoms.
Patient Age
*
Duration of Sore Throat (in days)
*
Severity of Sore Throat
*
No pain
1
2
3
4
5
6
7
8
9
Severe pain
10
1 is No pain, 10 is Severe pain
Has your child had a fever?
*
Yes
No
Unsure
Temperature (if measured, in °F or °C)
Select any of the following symptoms your child is experiencing:
*
Cough
Runny nose
Difficulty swallowing
Headache
Abdominal pain
Nausea or vomiting
Rash
None of the above
Does your child have a history of recent exposure to someone with strep throat?
*
Yes
No
Unsure
Does your child have any known allergies to medications?
*
Yes
No
If yes, please list medication allergies:
Please note: This assessment form is for informational purposes only and does not replace professional medical advice. Seek immediate care for severe symptoms.
Submit Assessment
Should be Empty: