Childhood illness intake that captures symptom severity up front
Parents share the child's age, current symptoms, and how severe things are, then confirm guardian status and attach notes or photos so your team can see who needs a same-day appointment.
Preview your childhood illness intake
Explore 7 questions from the Childhood Illness template. This interactive preview uses illustrative scoring and sample attachments. Open the full survey to try the complete intake.
What a qualified childhood illness lead should tell you
Intake covering a child's age, current symptoms, severity, and how long the illness has lasted, plus confirmation that the person submitting the form is authorized to make care decisions for the child.
- Child'S Current Age Range
- Would Describe Severity Current
- Long Has Child Had
- Symptoms Child Experiencing
- Child Already Been Evaluated
- Parent Or Legal Guardian
- Have Any Notes, Photos,
The questions your team needs answered
Every childhood illness intake asks these — and why each one matters.
| Question | Why it matters |
|---|---|
| What is the child's current age range? | Segments the lead so you can route, price, and prioritize it correctly. |
| How would you describe the severity of the current symptoms? | Severity is the strongest single indicator of how quickly this lead should be reviewed, with severe distress scoring well above a mild, active-and-eating presentation. |
| How long has the child had these symptoms? | Symptoms that started today read differently from ones recurring over weeks, which affects how quickly the case needs a slot. |
| Which symptoms is the child currently experiencing? | Breathing difficulty carries the highest weight of any symptom option, so its presence should pull a lead to the top regardless of what else is selected. |
| Has the child already been evaluated by a doctor for this illness? | Knowing whether another doctor has already evaluated the child helps staff distinguish a fresh concern from a case that is already being managed elsewhere. |
| Are you the parent or legal guardian able to make care decisions for this child? | A non-guardian answer scores much lower, prompting staff to confirm who can actually authorize care before the appointment is locked in. |
| Do you have any notes, photos, or records about the child's symptoms to share? | Notes, photos, or records shared here give staff visual or written context on symptoms before they ever speak with the parent. |
How Cliont scores childhood illness leads
Configured answer weights help your team prioritize follow-up. Your team reviews each submission and decides the next step.
Value signals
- Moderate, some discomfort or reduced activity
- Not sure
- Fever
- Cough or cold symptoms
- Digestive issues (vomiting, diarrhea)
- Rash or skin changes
Urgency signals
- Mild, child is active and eating normally
- Severe, significant discomfort or distress
See an example lead handoff
Illustrative lead details and score show how a submission can reach your team.
Childhood Illness Lead
From first click to qualified lead
Follow patients and caregivers through one smooth, guided flow.
They land & meet you
Your video greeting plays instantly — a real face instead of a blank form.
They explain the visit
Smart questions adapt to their visit and capture the full scope.
They share details
Symptoms, history, and documents come attached before the visit.
You get a ready lead
Scored and qualified — waiting for you to win it.
Built for childhood illness workflows
| Cliont capability | Childhood Illness application |
|---|---|
| Weighted multi-select scoring | Symptom combinations like fever plus breathing difficulty automatically score higher than a single mild symptom, so severe cases surface first. |
| Consent and authority checks | The guardian yes/no question is scored separately so a non-guardian submission is still routed but marked for a verification step before the appointment is confirmed. |
| File and note attachments | The free-text field lets parents reference symptom notes, photos, or prior records, which attach directly to the CRM lead instead of arriving as a separate email. |
| CRM routing | Completed childhood illness intakes, with severity and duration already captured, land in your CRM as qualified patients ready for staff to triage into an appointment slot. |
Example childhood illness lead scenarios
Illustrative situations explain the intake questions and possible follow-up.
Sudden high fever in a toddler
Symptoms started today with fever flagged as severe and the child under 3, so the intake surfaces this ahead of milder, longer-running cases.
Breathing difficulty reported
Any submission that selects breathing difficulty carries the highest symptom weight in the catalog, regardless of the child's age or how long symptoms have lasted.
Recurring symptoms over months
A child with symptoms recurring for weeks, mild severity, and a prior doctor evaluation reads very differently from a new, sudden case and can be routed for a standard follow-up instead of urgent review.
Caregiver without decision authority
When the person filling out the intake answers no to being the parent or legal guardian, the lower weight on that answer flags the submission so staff confirm who can actually authorize care before booking.
Mild cold, already seen by a doctor
Cough and cold symptoms marked mild, with the child already evaluated elsewhere, gives staff a lower-urgency read they can schedule around busier cases.
Connect Cliont to your workflow
Connect your CRM
HubSpot, HighLevel, monday.com
Connect your legal software
Lawmatics, MyCase, Clio Manage and Clio Grow
Notify your team
Email, SMS, Slack
Configure other destinations
Google Sheets, configured webhooks, Zapier and API workflows
Simple, transparent pricing
Choose the plan that works for your business.
Professional
Unlimited intake forms and leads for your growing business.
- Unlimited intake forms
- Custom video greetings
- AI-powered voice bot
- English + Spanish support
- Automatic lead scoring
- Digital estimates & e-signatures
- Photo, video & file upload
- Advanced analytics dashboard
Pay Per Lead
Only pay when you receive a qualified lead.
- Unlimited intake forms
- Custom video greetings
- AI-powered voice bot
- English + Spanish support
- Automatic lead scoring
- Digital estimates & e-signatures
- Photo, video & file upload
- Charged only for submitted leads
More pediatrics intake templates
Childhood Illness lead-intake FAQs
How does the intake tell apart a routine cold from something that needs same-day attention?
The severity question and the multi-select symptom list work together, so a mild cough scores very differently from severe distress paired with breathing difficulty, which carries the highest weight in the catalog.
What happens if a grandparent or babysitter submits the form instead of a parent?
The guardian question carries a much lower weight for a 'no' answer, so those submissions are still captured but flagged for staff to confirm who can authorize care before an appointment is booked.
Can parents attach photos of a rash or send notes from a previous visit?
Yes, the free-text field on the intake lets parents describe symptoms and reference or attach notes, photos, or records, which land on the lead card in your CRM alongside their answers.
Does it matter if the child has already been seen by another doctor for this illness?
Yes, that yes/no answer helps your team distinguish a first-time concern from an ongoing case someone else has already assessed, which changes how the appointment gets prioritized.
How does the child's age factor into how a lead is handled?
Age range is captured as its own question so staff reviewing the lead can weigh symptom severity against whether the patient is an infant, toddler, school-age child, or teenager.
Is this intake different from the one used for a Well-Child Visit or Behavioral Concerns?
Yes, this catalog is built specifically around acute and ongoing illness symptoms, severity, and duration, rather than the developmental or wellness questions used on sibling subservices like Well-Child Visit or Developmental Concerns.
Turn childhood illness visitors into qualified patients
Give every childhood illness visitor a guided intake instead of a dead contact form — and get a scored, qualified lead before you book front-desk time.