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Here with parent?
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What brings you here today?
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Is there anything else?
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Any other details?
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Do you have pain?
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Frequency
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For how long?
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Out of 10, pain level is usually:
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Location of pain?
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Pain increases with
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Pain decreases with
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Status?
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Do you have fatigue?
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Out of 10, if 10 is most fatigued:
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Daily Bowel Movement?
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Bowel movements per day?
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If not daily, BM per week?
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Sinus Congestion
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If so, describe mucus
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Runny Nose/Allergies
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If so, describe mucus
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Cough
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If so, describe mucus
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Additional symptoms
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Anything else we should know about?
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