99-5-3 What is wrong today?

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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

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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

Respiratory

Trouble breathing

Cough

Wheezing

Chest congestion

GI

Nausea

Vomiting

Diarrhea

Constipation

CMed Triage – Capturing Symptoms Details

Medical History and Triage

Reason for Todays Visit