Pediatric Discharge Symptom Assessment Form
Use this form to report a child’s symptoms and recovery after discharge so the care team can review current condition and follow-up needs.
Patient and Discharge Context
Caregiver Name
*
First Name
Last Name
Relationship to Child
*
Please Select
Mother
Father
Parent
Grandparent
Guardian
Other
Child's Age
*
Discharge Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Hospitalization/Visit
*
Symptom Assessment
Current Symptoms
*
Fever
Pain
Vomiting
Diarrhea
Cough
Breathing Difficulty
Rash
Poor Appetite
Sleepiness
No Symptoms
Other
Overall Symptom Severity
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Are the symptoms improving?
*
Improving
Unchanged
Worsening
Other Symptoms
Follow-up and Urgency
Have you already contacted the discharge team or pediatrician?
*
Yes
No
Preferred follow-up contact method
Please Select
Phone call
Text message
Email
Clinic appointment
No preference
Other
Additional notes or concerns
Submit Assessment
Should be Empty: