Pediatric Symptom Checklist Form Template

The Pediatric Symptom Checklist is a standardized screening tool to assess for social, emotional, and behavioral issues in children. Providers can use this information prior to the appointment to best direct the conversation and assessment of the child.
Pediatric-Symptom-Checklist

Pediatric Symptom Checklist Form Template

Give parents and guardians the freedom to complete the Pediatric Symptom Checklist with any device, anywhere. Enable them to answer sensitive questions in privacy at a comfortable and unhurried time.

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What is the Pediatric Symptom Checklist?

This form enables parents and guardians to express the changes they are seeing in their child’s behavior, emotions, or learning. Because parents/guardians know their children best, this is vital information for the provider to form a plan of care for the child.  

A child’s daily functioning is an expression of their strengths and stressors. A child’s functioning is the common pathway for the influence of genetics, their psychological development, social determinants of health, coping abilities, and resilience.

The liability falls on you to handle patient data in a compliant way. Patient privacy is a serious topic, legislation from the Health Insurance Portability and Accountability Act to the Patient Protection and Affordable Care Act place heavy fines on medical professionals who mistreat patient information.

A medical release form does not empower your staff to share patient information with just anyone. Depending on what is included in the form, the document may release medical information to the patient’s family, other doctors, insurance providers, attorneys, or anyone who may make healthcare decisions on behalf of the patient.

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Export Form Submissions to Excel

Export multiple patient forms into a Microsoft Excel compatible CSV file. Take control of your patient data with a bulk export, and import your complete patient forms into a database, excel spreadsheet, or EHR.

Required HIPAA Compliant Form Fields

Required Form Fields

Always get the information you need with required fields. Patients can only submit when they complete all of your required fields. Never receive an incomplete medical form again.

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Prefilled Forms

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