Weekly Symptom Checklist For Children Template Page 2
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WEEKLY SYMPTOM CHECKLIST FOR CHILDREN
Name
Date
Date of Birth ______________ Age ______ Height ______ Weight ______ Blood Type ______
Rate each of the following symptoms based on your child’s current health profile
0 - Never or almost never has the symptom
Point Scale
1 - Occasionally has symptoms
2 - Frequently has symptoms
HEAD
________
Headaches
________
Difficulty falling asleep
________
Wakes up during the night
Total ________
EYES
________
Watery or itchy eyes
________
Dark circles under eyes
________
Bags under eyes
________
Swollen eyelids
Total ________
EARS
________
Reddening of ears
________
Itchy ears
________
Earaches/Ear infections (circle which apply)
________
Drainage from ear
________
Hearing loss
________
Frequent pulling on ears
Total ________
NOSE
________
Runny nose
________
Stuffy nose
________
Sneezing
________
“Allergic Salute” (rubs, itches, wipes nose
frequently with hands)
Total ________
MOUTH/THROAT
________
Swollen or red lips
________
Gagging, frequent need to clear throat
________
Sore throat, hoarseness, loss of voice
________
Swollen or sore or discolored tongue
________
Swollen or sore gums or lips
________
Canker sores
Total ________
SKIN
________
Easy bruising
________
Hives
________
Rash
________
Dry or flaky skin
________
Flushing
________
Cold hands or feet
________
Eczema
Total ________
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Parent category: Life