Bacterial Infection Symptom Check Form
Answer the questions below to check for common symptoms associated with bacterial infections.
Full Name
First Name
Last Name
Email Address (optional, for follow-up)
example@example.com
Age
When did your symptoms begin?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Which of the following symptoms are you experiencing?
*
Fever
Chills
Redness or swelling
Pain or tenderness
Discharge or pus
Fatigue
Other
On a scale of 1 to 10, how severe are your symptoms?
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Do you have a known history of chronic illness?
No
Yes
Not sure
Have you recently taken antibiotics?
Yes
No
Not sure
Have you traveled recently?
Yes
No
Please describe any other symptoms or relevant details.
Check Symptoms
Should be Empty: