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Symptom Screening Form Template

Streamline your patient assessments with ease and efficiency

Determining the cause of a patient's symptoms can be challenging without the right tools. This symptom screening form template is designed for healthcare professionals seeking to gather essential information and streamline the assessment process. With easy customization options, you can create a patient-friendly form that helps identify symptoms, document important health data, and enhance communication with your team. Plus, it's compliant with accessibility standards, ensuring all patients can complete it easily. Try the live template for an efficient solution!

Use this Template (FREE) Live Preview
Full name
Date of birth
Email address
Phone number
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
When did your current symptoms start?
What is the main reason you are completing this screening today?
New symptoms
Exposure to illness
Pre-procedure screening
Return to work or school
Travel requirement
Follow-up on previous screening
Other
Please Specify:
Which symptoms are you currently experiencing?
What is the highest temperature you have measured, if any? (e.g., 101.3 F or 38.5 C)
How did your symptoms begin?
Suddenly
Gradually
Unsure
Not applicable
How severe are your symptoms today?
None
Mild
Moderate
Severe
Very severe
How often are your symptoms limiting your normal activities today?
Never
Rarely
Sometimes
Often
Always
In the last 14 days, have you had close contact with someone diagnosed with an infectious illness?
Yes
No
In the last 14 days, have you traveled outside your state/province or country?
Yes
No
Are you currently pregnant?
Yes
No
Not applicable
Prefer not to say
Do you have any of the following health conditions?
Please Specify:
Do you currently take medicines that weaken your immune system (e.g., steroids, chemotherapy, biologics)?
Yes
No
Unsure
Do you currently smoke or vape?
Yes
No
Former
Prefer not to say
Have you taken a COVID-19 or other infectious disease test in the last 10 days?
Yes
No
What was the most recent test result?
Positive
Negative
Inconclusive or invalid
Pending
Not applicable
Would you like a healthcare professional to follow up with you?
Yes
No
Preferred contact method
Phone call
Text message
Email
No follow-up needed
Are you experiencing any of the following emergency symptoms?
Severe difficulty breathing
Bluish lips or face
Severe chest pain
New confusion or inability to wake
Fainting
Seizures
None of the above
I confirm that the information provided is accurate to the best of my knowledge.
Yes
No
Signature
Date
I understand this screening does not provide a medical diagnosis and that I should seek emergency care for severe symptoms.
Yes
No
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Paper art illustration depicting a symptom screening form with checkboxes and medical symbols for FormCreatorAI article

When to use this form

Use this form to quickly screen people before appointments, shifts, classes, or events. It helps admins and clinicians capture symptoms, onset, exposure, and severity so you can decide who may enter, isolate, or seek care. Pair it with the Self-health assessment form for daily check-ins, and roll up risk factors with the Health risk assessment questionnaire form to prioritize follow-up. If symptoms look like allergies, reference the Allergy action plan form to clarify triggers and typical responses. For return-to-work or school, you can request a Physician statement form to document clearance. It benefits HR teams, school nurses, front desks, and telehealth staff, and speeds safe, consistent decisions.

Must Ask Symptom Screening Questions

  1. Which symptoms are you experiencing today?

    Use a clear list (fever, cough, sore throat, headache, nausea, diarrhea, rash, loss of taste or smell) plus an "other" field. Standardized options reduce confusion and make data easier to compare across locations and days.

  2. When did your symptoms start, and how have they changed?

    Onset and trend help you judge stage of illness and urgency. Early worsening may require isolation or rapid follow-up, while stable mild symptoms often allow watchful waiting.

  3. Have you had a measured fever (100.4 F/38 C) or any red-flag symptoms such as chest pain or severe shortness of breath?

    These signs trigger immediate precautions and clear next steps. If a clinician has already evaluated you, you can attach a Doctor diagnosis form to document findings.

  4. In the past 14 days, have you had close contact with someone who is ill or tested positive?

    Exposure history changes risk level and may require testing or quarantine. It also guides contact tracing and protects coworkers, patients, and students.

  5. Do you have allergies or chronic conditions that could explain these symptoms, and do workplace or school rules require you to notify a manager or nurse?

    Context reduces false alarms and keeps records compliant. Knowing whether symptoms must be reported ensures you follow policy and helps route next steps.

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