Clinical Symptom Intake Assessment Checklist Form
Complete this assessment checklist to share current symptoms, timing, severity, and follow-up preferences.
Patient Intake
Full Name
*
First Name
Last Name
Age
*
Primary Reason for Intake Today
*
Symptom Details
When did the symptoms start?
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Symptom severity
*
1
2
3
4
5
How are the symptoms changing?
*
Getting better
Getting worse
Staying the same
Anything that seems to worsen the symptoms?
Care and Follow-up
Self-care or over-the-counter steps already taken
Rest
Fluids
Over-the-counter medicine
Home remedies
None yet
Other
Preferred follow-up contact method
*
Phone
Email
Text message
Other
Submit
Should be Empty: