Download as docx, pdf, or txt
Download as docx, pdf, or txt
You are on page 1of 1

CLINIC VISIT RECORD CLINIC VISIT RECORD

DATE: TIME: DATE: TIME:

STUDENT NAME: STUDENT NAME:

GRADE & SECTION: GRADE & SECTION:

CHIEF COMPLAINTS: CHIEF COMPLAINTS:

I don’t feel good I don’t feel good

My eyes are irritated My eyes are irritated

I have headache I have headache

I have a scratch/cut I have a scratch/cut

Where? Where?

I have PAIN (circle) I have PAIN (circle)

- Stomach - Legs - Stomach - Legs


- Throat - Arms/hands - Throat - Arms/hands
- Ears - Neck - Ears - Neck
- Back (lower/upper) - Back (lower/upper)

Nurse’s notes & assessment: Nurse’s notes & assessment:

You might also like