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99-5-2 What is wrong today?
CMed Triage – More Details on Your Symptoms
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Symptoms/Issues Related to Why you are coming in
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
MM slash DD slash YYYY
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Visit ID
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Pull Data
– Fill Out Other Fields –
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Pat ID
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Clinic ID
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Reason Visit Category
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EMR Reason Visit ID
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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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Reason for coming in today
Which BEST describes your illness? (Select one)
(Required)
Cough/congestion/sore throat/Ear pain
Abdominal pain/Nausea/Vomiting/Diarrhea
Urinary/genital problem
Chest pain/Shortness of breath
Headache/Dizziness/Lightheaded/Palpitations
Skin problem
Eye problem
Pain in site not listed above (I have this option bc sometimes it isn’t from injury)
Q1
Which BEST describes your pain/injury/wound? (select one)
(Required)
Cut/punctured skin
Bite
Pain with no injury
Fall
Struck by/ran into object
Sports injury
Other
Q2
Where is your Pain/Injury (select all that apply):
(Required)
Arm/Wrist/Hand
Leg/Ankle/Foot
Neck/Back
Head/Face
Chest/abdomen
Q3
Where is your Pain/Injury (select all that apply):
(Required)
Arm/Wrist/Hand
Leg/Ankle/Foot
Neck/Back
Head/Face
Chest/abdomen
Q3 T2
Where is your Pain/Injury (select all that apply)-:
(Required)
Arm/Wrist/Hand
Leg/Ankle/Foot
Neck/Back
Head/Face
Chest/abdomen
Q4
Where is your Pain/Injury (select all that apply)-:
(Required)
Arm/Wrist/Hand
Leg/Ankle/Foot
Neck/Back
Head/Face
Chest/abdomen
Q4 T2
Which BEST describes your Injury? (select one)
(Required)
Cut/punctured skin
Pain without open wound
Other
Q5
Where is your Pain/Injury (select all that apply)-
(Required)
Arm/Wrist/Hand
Leg/Ankle/Foot
Neck/Back
Head/Face
Chest/abdomen
Q6
-Which BEST describes your Pain/Injury/Wound? (select one)
(Required)
Cut/punctured skin
Bite
Pain with no injury
Fall
Struck by/ran into object
Other
Q7
-Where is your Pain/Injury (select all that apply)
(Required)
Arm/Wrist/Hand
Leg/Ankle/Foot
Neck/Back
Head/Face
Chest/abdomen
Q8
-Where is your Pain/Injury (select all that apply)-
(Required)
Arm/Wrist/Hand
Leg/Ankle/Foot
Neck/Back
Head/Face
Chest/abdomen
Q9
Thanks – lets go to work to get you getter!
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With a few more simple questions, we can capture your symptom details and shorten your visit by 10-15 minutes
Lets go – I will do it now
In a bit – Text and email me a link and I will finish before my visit
No – I hate electronics and want to do it with a live person
