99-5-2 What is wrong today?

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Tell Us More About Why You Are Coming In

Please answer a couple more 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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Pat ID

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visit Date

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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 Injury? (select one)(Required)

Cut/punctured skin

Pain without open wound

Other

Q5

Because our practitioner is virtual today, we are unable to treat cuts or lacerations

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

Because our practitioner is virtual today, we are unable to treat cuts or lacerations

Thanks – You are all set and your registration will be finished when you click the COMPLETE my registration button below – we will work to get you feeling better!

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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

CMed Triage – More Details on Your Symptoms

Tell Us More About Why You Are Coming In