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99-5-3 What is wrong today?
CMed Triage – Capturing Symptoms Details
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Medical History and Triage
Please answer or confirm your previous answers to these medical screening questions
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Traffic Source
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Decimal Time
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Date
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Visit ID
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Pull Data
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Clinic ID
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Reason Visit Category
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Patient Name
First
Last
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Patient Phone
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Clinic Name
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Patient Sex
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Systems Displaying
Constitutional
Eyes
ENT
Cardiovascular
Respiratory
GI
GU
Musculosekeletal
Skin
Neurological
Psychiatric
Endocrine
Hemat-Lymph
Allery-Immuno
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Reason for Todays Visit
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Reason for coming in today
Please check all symptoms that apply to your CURRENT condition you are being seen for
Constitutional
Fever
Chills/sweats
Change in appetite
Fatigue
Cardiovascular
Chest Pain
Palpitations
Leg Swelling
Neurovascular
Headache
Numbness/Tingling
Fainting/Passed out
Please check all symptoms that apply to your CURRENT condition you are being seen for
Allergy
Lip or tongue swelling
Sneezing
Post-nasal drip
Eyes
Eye redness
Eye discharge
Eye pain
Blurry/distorted vision
Ears
Ear pain
Ear discharge
Ear wax
Trouble hearing
Please check all symptoms that apply to your CURRENT condition you are being seen for
Respiratory
Trouble breathing
Cough
Wheezing
Chest congestion
GI
Nausea
Vomiting
Diarrhea
Constipation
Please check all symptoms that apply to your CURRENT condition you are being seen for
GU
Frequent urination
Painful urination
Genital rash/sores
Genital discharge
Musculoskeletal
Sprain
Joint injury
Muscle pain
Skin
Rash
Hives
Abscess/boil
Laceration cut
Please check all symptoms that apply to your CURRENT condition you are being seen for
Psychiatric
Rash
Hives
Abscess/boil
Laceration cut
Lymphatic
Rash
Hives
Abscess/boil
Laceration cut
Endochrine
Rash
Hives
Abscess/boil
Laceration cut
