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Paediatric ENT

Menu

Home
About Us
Locations
Contact Us
Chinese / 中文
Patient Resources
Procedures
ENT Services / Conditions Treated
- Allergy
- Ears
- Head and Neck
- Nose and Mouth
- Paediatric
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- Throat
Paediatric ENT

Head and Neck Patient Symptom Checklist

Home > Procedures > Patient Resources > Head and Neck Patient Symptom Checklist

During the past 3 days	How often did you have this symptom?
Symptoms	Not at all	A little bit	Some what	Quite a bit	A lot
	1	2	3	4	5

Name(Required)

First Last

Phone(Required)

Email(Required)

Pain

1

2

3

4

5

Anxious

1

2

3

4

5

Dry Mouth

1

2

3

4

5

Loss of appetite

1

2

3

4

5

Constipation

1

2

3

4

5

Feeling full

1

2

3

4

5

Depressed

1

2

3

4

5

Thick saliva

1

2

3

4

5

Diarrhea

1

2

3

4

5

Sore mouth

1

2

3

4

5

Lack of energy

1

2

3

4

5

Nausea

1

2

3

4

5

Difficulty chewing

1

2

3

4

5

Smells bother me

1

2

3

4

5

Vomiting

1

2

3

4

5

Difficulty swallowing

1

2

3

4

5

Taste changes

1

2

3

4

5

Other - specify

1

2

3

4

5

Total

Hidden

Has this symptom interfered with your eating?

Has this symptom interfered with your eating?
Not at all	A little bit	Some what	Quite a bit	A lot
1	2	3	4	5

Pain

1

2

3

4

5

Anxious

1

2

3

4

5

Dry Mouth

1

2

3

4

5

Loss of appetite

1

2

3

4

5

Constipation

1

2

3

4

5

Feeling full

1

2

3

4

5

Depressed

1

2

3

4

5

Thick saliva

1

2

3

4

5

Diarrhea

1

2

3

4

5

Sore mouth

1

2

3

4

5

Lack of energy

1

2

3

4

5

Nausea

1

2

3

4

5

Difficulty chewing

1

2

3

4

5

Smells bother me

1

2

3

4

5

Vomiting

1

2

3

4

5

Difficulty swallowing

1

2

3

4

5

Taste changes

1

2

3

4

5

Other - specify

1

2

3

4

5

Total

Comments

This field is for validation purposes and should be left unchanged.

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242 Great South Road
Greenlane
Auckland

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Throat

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242 Great South Road
Greenlane
Auckland

Menus

Home
About Us
Locations
Contact Us

Quick links

Conditions
Patient Resources
Procedures
Paediatric ENT

Procedures

Audiology
General
Head and neck
Laryngology
Otology
Rhinology
Speech therapy

Conditions treated

Allergy
Ears
Head and Neck
Nose and Mouth
Paediatric
Skin Lesions
Throat

Auckland ENT Group © 2021 All rights reserved

Developed and Designed by AMPM Web & Digital