Stroke Symptom Checklist Form
Complete this Stroke Symptom Checklist Form to assess potential stroke symptoms and provide important follow-up details.
Full Name
*
First Name
Last Name
Date and Time Symptoms Began
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Which of the following symptoms are present?
*
Sudden numbness or weakness in the face, arm, or leg (especially on one side)
Sudden confusion, trouble speaking, or understanding speech
Sudden trouble seeing in one or both eyes
Sudden trouble walking, dizziness, loss of balance or coordination
Severe headache with no known cause
Other
Describe how the symptoms started and any changes over time
Have these symptoms occurred before?
Yes
No
Are you currently taking any medications?
Yes
No
If yes, please list your current medications
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address (for follow-up)
example@example.com
Submit Checklist
Should be Empty: