Symptom Assessment Prompt Templates

Headache Assessment Guide

Start Here:
'Tell me about your headache. When did it start and what does it feel like?'

Timing and Pattern:
• When did this headache start? (sudden vs. gradual)
• Is this the worst headache of your life? (critical question)
• How long does it last? Is it constant or does it come and go?
• Have you had headaches like this before?
• How often do you get headaches?

Character and Location:
• Where exactly is the pain? One side or both?
• What does it feel like? (throbbing, pressure, stabbing, band-like)
• On a scale of 1-10, how bad is it?
• Does it spread anywhere? (neck, face, eyes)

Associated Symptoms:
• Any nausea or vomiting?
• Sensitivity to light or sound?
• Any vision changes? (blurry, double, flashing lights, blind spots)
• Any numbness, weakness, or trouble speaking?
• Any fever or stiff neck?
• Any recent head injury?

Triggers and Relief:
• What were you doing when it started?
• Does anything make it better? (dark room, lying down, medications)
• Does anything make it worse? (bending over, coughing, bright lights)
• Have you tried any medications? Did they help?

RED FLAGS - Escalate Immediately If:
□ 'Worst headache of my life' or 'thunderclap' onset
□ Fever with stiff neck
□ New neurological symptoms (weakness, numbness, confusion, vision loss)
□ Headache after head trauma
□ Headache that wakes them from sleep
□ Progressive worsening over days/weeks
□ New headache in patient over 50
□ Headache with cancer history or immunocompromised state

Relevant History:
• History of migraines or other headache disorders?
• Any recent illness or infection?
• History of high blood pressure?
• Any blood thinners or bleeding disorders?
• Recent dental work or sinus problems?

Medications to Review:
• Current headache medications (overuse can cause rebound)
• New medications started recently
• Birth control or hormone therapy
• Blood thinners

Abdominal Pain Triage Guide

EMERGENCY - Call 911 or Go to ER Now:
• Severe pain that came on suddenly
• Pain with fainting, dizziness, or confusion
• Vomiting blood or blood in stool (red or black/tarry)
• Rigid, board-like abdomen (won't let you touch it)
• Pain with high fever (over 103°F)
• Pregnant with abdominal pain and/or vaginal bleeding
• Recent abdominal surgery with new severe pain
• Pain with inability to urinate
• Known abdominal aortic aneurysm with new pain

Example: 'I have sudden severe pain in my belly, I'm sweating, and I feel like I might pass out.'

URGENT - Same-Day Appointment:
• Moderate to severe pain that's been getting worse
• Pain with fever (100.4-103°F)
• Pain with persistent vomiting (can't keep fluids down)
• Pain localized to right lower abdomen (possible appendicitis)
• Pain localized to right upper abdomen after eating (possible gallbladder)
• Burning with urination plus back/flank pain (possible kidney infection)
• No bowel movement in 4+ days with cramping

Example: 'I've had pain in my right side for two days, it's getting worse, and I had a fever of 101 this morning.'

SOON - Appointment Within 1-2 Days:
• Mild to moderate pain that's stable or improving
• Cramping with diarrhea but no blood or fever
• Heartburn not responding to antacids
• Bloating and discomfort after meals
• Constipation without severe pain or vomiting
• Mild pain with normal appetite and no fever

Example: 'I've had some stomach cramping and loose stools for a couple days, but no fever and I'm keeping fluids down.'

ROUTINE - Can Wait for Regular Appointment:
• Occasional mild discomfort
• Chronic symptoms that haven't changed
• Mild bloating or gas
• Heartburn that responds to over-the-counter medications
• Questions about diet and digestion

Example: 'I get some bloating after I eat dairy. It's been happening for months, nothing new.'

Always Ask:
• When did it start?
• Where exactly is the pain?
• How severe is it (1-10)?
• Any fever, vomiting, or changes in bowel movements?
• Any blood in vomit or stool?
• Could you be pregnant?
• Any recent surgery or procedures?

Chest Pain Documentation Template

PATIENT: [Name] | DOB: [Date] | Date/Time: [Now]

CHIEF COMPLAINT: Chest pain

ONSET: □ Sudden □ Gradual
Started: [Date/time or 'X hours/days ago']
Doing what when it started: _______________

LOCATION:
□ Substernal □ Left chest □ Right chest
□ Radiates to: □ Left arm □ Right arm □ Jaw □ Back □ Neck
□ Localized (can point to it with one finger) □ Diffuse

QUALITY:
□ Pressure/squeezing □ Sharp/stabbing □ Burning
□ Aching □ Tearing □ Other: _______

SEVERITY: ___/10
Worst it's been: ___/10

DURATION:
□ Constant since onset
□ Intermittent. Each episode lasts: _______

PROVOKING/RELIEVING:
Worse with: □ Exertion □ Breathing □ Movement □ Eating □ Lying flat □ Nothing specific
Better with: □ Rest □ Nitroglycerin □ Antacids □ Position change □ Nothing

ASSOCIATED SYMPTOMS:
□ Shortness of breath □ Diaphoresis (sweating)
□ Nausea/vomiting □ Palpitations
□ Dizziness/lightheadedness □ Syncope
□ Cough □ Fever
□ Leg swelling □ Recent immobility/travel

PERTINENT NEGATIVES:
□ No radiation □ No shortness of breath
□ No diaphoresis □ No syncope
□ Not pleuritic □ No leg swelling
□ No recent travel/immobility

CARDIAC RISK FACTORS:
□ Hypertension □ Diabetes □ Hyperlipidemia
□ Smoking: □ Current □ Former (quit ___)
□ Family history of early CAD
□ Prior MI/stent/CABG
□ Known CAD

PREVIOUS SIMILAR EPISODES:
□ No □ Yes - describe: _______________
Previous cardiac workup: _______________

MEDICATIONS TRIED:
□ Nitroglycerin - response: _______________
□ Aspirin □ Antacids □ Other: _______________

CURRENT MEDICATIONS: [List]
ALLERGIES: [List]

ASSESSMENT/TRIAGE DECISION:
□ 911/ER immediately □ Urgent eval today
□ Appointment within 24-48h □ Routine

Rationale: _______________

UTI Follow-Up Assessment (Day 3 of Treatment)

Original Presentation: UTI symptoms, started nitrofurantoin 3 days ago

Expected by Now: Burning and frequency should be significantly better. Most patients feel 50-75% improved by day 3.

Questions to Ask:

Symptom Status:
'How are you feeling compared to when we started the antibiotic?'
□ Much better □ Somewhat better □ Same □ Worse

'Are you still having burning when you urinate?'
□ Resolved □ Improved □ Same □ Worse

'How often are you going to the bathroom?'
□ Back to normal □ Still frequent but better □ No change

New or Worsening Symptoms:
'Any new symptoms since starting the medication?'
□ Fever (ask: how high?)
□ Back pain or flank pain
□ Nausea or vomiting
□ Blood in urine
□ Chills or shaking

Medication Adherence:
'Have you been able to take all your doses?'
'Any problems with the medication?' (nausea, rash, etc.)

RED FLAGS - Escalate to Same-Day Visit or ER:
• Fever over 101°F
• New back/flank pain (concern for pyelonephritis)
• Vomiting (can't keep medication down)
• Symptoms significantly worse despite 48+ hours of antibiotics
• Rigors (shaking chills)
• Confusion or altered mental status (especially in elderly)

TREATMENT WORKING (Expected):
• Symptoms improving
• No fever
• Tolerating medication
→ Action: Complete the antibiotic course. No further follow-up needed unless symptoms return.

TREATMENT PARTIALLY WORKING:
• Some improvement but still symptomatic
• No red flags
→ Action: Continue antibiotic, reassess in 2 more days. Consider urine culture if not done initially.

TREATMENT NOT WORKING:
• No improvement or worsening after 48-72 hours
• Concern for resistant organism or wrong diagnosis
→ Action: Bring in for evaluation. Urine culture, consider changing antibiotic, rule out complications.

COMPLICATION SUSPECTED:
• Fever, flank pain, vomiting, or systemic symptoms
→ Action: Same-day visit or ER depending on severity. May need IV antibiotics, imaging.