JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
PANDAS Follow-up Assessment Form
Please complete this form for your follow-up appointment
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Children's e-Hospital Identity Number
*
Your answer
Todays date
*
MM
/
DD
/
YYYY
Child's Name
*
Your answer
What treatment has your child received since your last appointment?
*
Co-amoxiclav
Amoxicillin
Penicillin
Azithromycin
Clarithromycin
Cefalexin
Ibuprofen
Prednisolone
Dexamethasone
Nystatin
Fluconazole
None
Required
Please give as much detail about your child's progress since treatment started. If your child has Obsessive Compulsive Behaviour or Tics please fill in the additional assessment forms
*
Your answer
On a scale of 1-10 how much has your child's symptoms improved since treatment started?
*
No Improvement
1
2
3
4
5
6
7
8
9
10
Complete Resolution of Symptoms
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Children's e-Hospital.
Report Abuse
Forms
