Medical Symptoms Checklist Template

Template Instructions

SurveyPluto's medical symptoms checklist template is expertly designed to help track symptoms experienced over the last 14 days, offering patients and healthcare providers a precise tool for monitoring health concerns. This free survey template is the perfect solution for enhancing patient consultations, facilitating a more efficient and effective approach to health monitoring. Ready to enhance your approach to health monitoring? Click "Use This Template" to get started.


Medical Symptoms Checklist Template

15
Questions
Use This Template

Medical Symptoms Checklist Template

Please mark the symptoms you have experienced in the last 14 days. If a symptom is not listed, use the space provided at the end to describe it.
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*
1.
Your full name
*
2.
Your gender
Female
Male
*
3.
Fever or Chills
Yes
No
*
4.
Cough
Yes
No
*
5.
Shortness of Breath or Difficulty Breathing
Yes
No
*
6.
Fatigue
Yes
No
*
7.
Muscle or Body Aches
Yes
No
*
8.
Headache
Yes
No
*
9.
New Loss of Taste or Smell
Yes
No
*
10.
Sore Throat
Yes
No
*
11.
Congestion or Runny Nose
Yes
No
*
12.
Nausea or Vomiting
Yes
No
*
13.
Diarrhea
Yes
No
15.
Additional Symptoms (Please specify any symptoms not listed above)
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