Registration – Specialty Forms

This field is hidden when viewing the form

HIDDEN Visit ID

This field is hidden when viewing the form

Decimal Time

This field is hidden when viewing the form

Today Date

MM slash DD slash YYYY

This field is hidden when viewing the form

Source

This field is hidden when viewing the form

Lookup Visit Entries

This field is hidden when viewing the form

Patient DOB Date

MM slash DD slash YYYY

This field is hidden when viewing the form

Patient Age

This field is hidden when viewing the form

Patient Name

First Last

This field is hidden when viewing the form

Patient Mobile

This field is hidden when viewing the form

Patient Email

This field is hidden when viewing the form

Visit Reason

This field is hidden when viewing the form

Clinic

This field is hidden when viewing the form

HIDDEN Clinic front desk cell Phone

Additional Questions

Because your visit is related to a motor vehicle accident, we need to ask a few more questions about the accident to make sure we get you properly diagnosed and we can properly bill for your visit.

Additional Questions

Because your visit is related to a workplace injury, we need to ask a few more questions to make sure we get you properly diagnosed and we can properly bill for your visit.

Additional Questions

Because your visit is related to a drug screening, we need to ask a few more questions to make sure we follow proper drug test procedure and we can properly bill for your visit.

Additional Questions

Because your visit is related to a DOT Physical, we need to ask a few more questions to make sure we gather the proper information to complete your physical.

Additional Questions

Because your visit is related to a School Physical, we need to ask a few more questions to make sure we gather the proper information to complete your physical.

This field is hidden when viewing the form

Section Break

St-3 P-1

Car Accident Questions

Necessary for us to properly diagnose the injury and file for reimbursement from insurance.

Do you have Personal Injury Protection (PIP) on YOUR car insurance?

Yes

Don't Know

Location of Patient during the accident

Driver

Front Passenger

Rear Seat Passenger

Other

Approximate accident speed (MPH)

<10

10-19

20-29

30-39

40-54

55-70

70+

Collision with:

Another vehicle

Stationary Object (tree, wall, fence, etc.)

Pedestrian

Animal

Other

This field is hidden when viewing the form

Where on the car did it hit?

Front bumper

Driver side

Passenger side

Rear bumper

Other

This field is hidden when viewing the form

Patient estimate of the force of the collision

Low

Medium

High

Other

How direct was the collision?

Direct impact

Scrape of glancing collision

What was the Patients seat belt situation?

None

Shoulder and lap belt

Lap belt only

Car seat

Can't remember

Other

Other Characteristics of the accident (check all that apply):

Air bag deployed

Patient thrown from vehicle

Patient had to have EMS/Firefighters get them from the car

Patient was treated by EMS at the scene

Other details:

Other Motor Vehicle Accident details:

I approve CommunityMed to file with insurance for reimbursement(Required)

Yes, and I realize that if insurance does not pay, I will be responsible for the balance due for the visit

This field is hidden when viewing the form

Section Break

St-3 P-2

Car Insurance Info

We will file the visit with valid motor vehicle insurance. Please provide the details below:

Auto Policy Number

Accident Claim Number

Date of Motor Vehicle Injury

YYYY

Insurance Company Name

Insurance Company Phone Number

Insurance Adjuster's Name

First Last

Insurance Adjuster Phone Number

Insurance Adjuster Email Address (If known)

PLEASE bring YOUR auto insurance card in with you

This field is hidden when viewing the form

Section Break

St-3 P-3

Work Place Medicine

Employer Previously Listed

This is a Corporate Remedies covered employer visit

Yes, this visit is Corporate Remedies

Is this occupational medicine or work injury visit for an employer already contracted with us, or is this a walk-in?

Employer is already contracted with CommunityMed

Patient is a walk-in occ med or workplace injury

Unsure

Is your employer paying for these services?

Yes

Does the patient have their eScreen form with barcode

Yes

What type of paperwork was issued to you? Please select who your “Service Request” has been issued from:

Escreen, ePassport, Passport, Quest, Qpassport, First Advantage, LabCorp (move to next page)

Other

Describe Other paperwork issuesd to you

Verification of Driver's Identity by

Other method Identity is Confirmed

Work Injury Authorisation Details

Legal Name of Company from Authorization Form

Name of person authorizing you to come in for a work injury

Phone number of the person authorizing you to come in for a work injury

Workplace Injury Details

Date of Injury

Approximate Time of the injury

Hours

Minutes

AM/PM

Did you report the injury to your employer?

Yes

To who at your employer (person's name) did you report the injury?

Date you reported it

MM slash DD slash YYYY

What is your injury?

Select the part(s) of your body injured

Hold CTRL to select multiple entries

Describe the circumstances around you getting this injury

Have you had a previous injury on these body parts?

Yes

This field is hidden when viewing the form

Section Break

St-3 P-4

WE WILL SEND YOU THE UIL FORM

We will email you the UIL form as a fillable PDF for you to complete PRIOR to coming in.

Do you need additional physical paperwork completed for camp etc.?(Required)

Yes

There is an additional charge per form set of $10 (applicable to both free wellness school physical and cash pay $49 physical)

Are you requesting the optional EKG as part of your child's physical?(Required)

Yes

NOTE:

CommunityMed does not perform Pediatric ECGs. If you notate on your youth's UIL physical form (near the bottom right of the first page) that you would like a Pediatric ECG completed, CommunityMed will need to refer you and your youth to a Pediatric Cardiologist to undertake the ECG (with additional charges from the cardiologist). Eliminating the ECG request on your school physical paperwork will allow us to complete the physical today. We are happy to still refer you to a great cardiologist if the ECG is important to you and your child.

Has your child suffered a concussion within the last year?(Required)

Yes, Child has suffered a concussion in the past year

IMPORTANT NOTE ON CONCUSSIONS:

If you answered yes (your child has suffered a concussion within the last year) you need to provide a clearance letter. CommunityMed is UNABLE to clear your child from a recent concussion.

WITH YOU TODAY - Do you have a copy of the physician clearance letter/note from this concussion(Required)

Yes

Is it likely that your child need eye glasses to pass an eye exam at 20/40(Required)

Yes

Important Vision Test Info:

If your child requires glasses or contacts to read an eye chart, you must have those to pass the physical exam. Your child will NOT pass if they cannot read at least 20/40 on the eye chart.

WITH YOU TODAY - Do you have your child's eye glasses?(Required)

Yes

Has a physician ever denied or restricted child's participation in activities for any heart problems?(Required)

Yes

IMPORTANT CARDIAC NOTE:

With the significant risk to your child given their cardiac history, we will need a copy of the clearance letter/note from the child's physician that restricted their activity due to heart problems.

WITH YOU TODAY - Do you have a copy of the clearance letter/note from the child's physician that restricted their activity due to heart problems?(Required)

Yes

YOUR CHILD IS UNLIKELY TO PASS THE SCHOOL PHYSICAL

Please rectify the requests for outside doctor notes and/or eye glasses in order to proceed with registration and get your child through their physical without issue.

This field is hidden when viewing the form

Section Break

St-3 P-5

DOT Physical

Verification of Driver's Identity By:

Other method Identity is Confirmed

DOT Physical Preliminary Questions

We need an answer to a few simple questions to get you in the queue for a more comprehensive questionnaire

Is this an existing commercial driver's license

YES

NO, this is a Commercial learners Permit

Reason for New DOT Physical(Required)

Driver's License State(Required)

Commercial Driver's License Number(Required)

Has your USDOT/FMCSA medical certificate ever been denied or issued for less than 2 years?

Yes

Not Sure

Do you have a recent history or have you been diagnosed with high blood pressure?(Required)

yes

WITH YOU TODAY - Do you have Do you have an active prescription to control your high blood pressure?(Required)

yes

Not Applicable

This field is hidden when viewing the form

Hidden HBP uncontrolled

This field is hidden when viewing the form

Section Break

St-3 P-6

Do you have a recent history or have you been diagnosed with Diabetes?(Required)

yes

WITH YOU TODAY do you have at LEAST ONE of the following: Most recent (within past 90 days) Hemoglobin A1C result OR recent blood sugar logs OR other record of Diabetes management?

I have AT LEAST one of the items listed above

I DO NOT have any of the items listed

This field is hidden when viewing the form

Hidden Diabetes uncontrolled

Do you use a CPAP machine?(Required)

Yes

Do you have documentation WITH YOU TODAY of proper use of the machine over the past 90 days?(Required)

Yes

Sometimes the machine has an app or web history.

This field is hidden when viewing the form

Hidden cpap uncontrolled

Do you have a history of a stroke, seizure disorder, brain tumor, or bleeding in the brain?(Required)

yes

WITH YOU TODAY - do you have a release letter from your Neurologist including documentation of any medications(Required)

Yes

This field is hidden when viewing the form

Hidden neuro uncontrolled

This field is hidden when viewing the form

Section Break

St-3 P-7

Do you have a recent history or diagnosis of heart related medical issues?(Required)

yes

WITH YOU TODAY - do you have a release letter from your cardiologist indicating your ability to safely drive a DOT vehicle AND documenting current medications(Required)

yes

This field is hidden when viewing the form

Hidden cardio uncontrolled

Are you currently prescribed medications (Ambien, Adderall, Bentos) that may cause sedation, sleepiness, or have a warning about operating machinery or vehicles(Required)

yes

WITH YOU TODAY - do you have a release letter (within the last 90 days) and medical documentation on the safety of taking these medications and driving a commercial vehicle(Required)

yes

This field is hidden when viewing the form

Hidden medication uncontrolled

Have you permanently lost use of any limb(Required)

yes

WITH YOU TODAY - do you have a note from a medical provider describing the injury and any required work restrictions(Required)

yes

This field is hidden when viewing the form

Hidden lost limb uncontrolled

This field is hidden when viewing the form

Section Break

St-2 P-8

Are you currently taking blood thinners?(Required)

yes

WITH YOU TODAY - do you have documentation from a medical provider indicating you INR (Internationalized-normalized ratio)(Required)

Yes

This field is hidden when viewing the form

Hidden INR uncontrolled

What is your height: FEET(Required)

INCHES(Required)

This field is hidden when viewing the form

What is your height in inches

What is your weight in lbs(Required)

This field is hidden when viewing the form

Calculated BMI

WITH YOU TODAY - do you have a documented sleep study(Required)

yes

Your BMI was over the 40 threshold requiring a sleep study to release you for DOT

This field is hidden when viewing the form

Hidden sleep study uncontrolled

Do you wear corrective lenses or contact lenses or hearing aids?(Required)

yes

Do you have those lenses/glasses or hearing aid with you today for the exam?(Required)

yes

This field is hidden when viewing the form

Hidden lenses aid uncontrolled

This field is hidden when viewing the form

DOT Fail flag

Because you are missing required documentation of your medical history/conditions, we will be unable to complete a DOT exam for you today

Please return and/or reschedule when you have the necessary documentation.
Click here for a list of required DOT exam documentation

FOR CASH-PAY DOT - Acknowledging Payment for test, regardless of pass/fail(Required)

Check here to acknowledge that you understand that you must pay for the DOT test, regardless of pass or fail. We set aside the time for your test and turned away other patients. Should you fail the test for any reason, including high blood pressure, incomplete docuemntation, or any other reason, you will not receive a refund.

This field is hidden when viewing the form

Section Break

St-3 P-9

HIDDEN clinc reg email

This field is hidden when viewing the form

payment method

This field is hidden when viewing the form

Reason for visit

This depression screening needs to be completed by the child, and a copy will be sent to the provider as a part of the school physical registration

This field is hidden when viewing the form

Date Completed

MM slash DD slash YYYY

This field is hidden when viewing the form

Source

TO BE ANSWERED BY PATIENT - OVER THE LAST WEEK, HOW HAVE YOU BEEN "ON AVERAGE" OR "USUALLY" REGARDING THE FOLLOWING ITEMS:

1. Low mood, sadness, feeling blah or down, depressed, just can't be bothered.(Required)

Hardly Ever

Much of the time

Most of the time

All of the time

2. Irritable, loosing your temper easily, feeling pissed off, loosing it.(Required)

Hardly Ever

Much of the time

Most of the time

All of the time

3. Sleep Difficulties - different from your usual (over the years before you got sick): trouble falling asleep, lying awake in bed.(Required)

Hardly Ever

Much of the time

Most of the time

All of the time

4. Feeling Decreased Interest In: hanging out with friends; being with your best friend; being with your partner / boyfriend / girlfriend; going out of the house; doing school work or work; doing hobbies or sports or recreation.(Required)

Hardly Ever

Much of the time

Most of the time

All of the time

5. Feelings of worthlessness, hopelessness, letting people down, not being a good person.(Required)

Hardly Ever

Much of the time

Most of the time

All of the time

6. Feeling tired, feeling fatigued, low in energy, hard to get motivated, have to push to get things done, want to rest or lie down a lot.(Required)

Hardly Ever

Much of the time

Most of the time

All of the time

7. Trouble concentrating, can't keep your mind on schoolwork or work, daydreaming when you should be working, hard to focus when reading, getting "bored" with work or school.(Required)

Hardly Ever

Much of the time

Most of the time

All of the time

8. Feeling that life is not very much fun, not feeling good when usually (before getting sick) would feel good, not getting as much pleasure from fun things as usual (before getting sick).(Required)

Hardly Ever

Much of the time

Most of the time

All of the time

9. Feeling worried, nervous, panicky, tense, keyed up, anxious.(Required)

Hardly Ever

Much of the time

Most of the time

All of the time

10. Physical feelings of worry like: headaches, butterflies, nausea, tingling, restlessness, diarrhea, shakes or tremors.(Required)

Hardly Ever

Much of the time

Most of the time

All of the time

11. Thoughts, plans or actions about suicide or self-harm.(Required)

No thoughts or plans or actions

Occasional thoughts, no plans or actions

Frequent thoughts, no plans or actions

Plans and/or actions that have hurt

This field is hidden when viewing the form

Total Score

This field is hidden when viewing the form

Section Break

St-3 P-10

Upload Drug Screen Authorization

Do you have an authorization form for your drug screen?

Yes, I have a paper or electronic authorization form, e-passport, or other documentation

No, I have no documentation for drug screen

Upload Drug Screen Authorization

Join our Parking Lot WIFI

Uploading photos of your forms can be frustrating if you are on a weak cell phone signal

We have setup safe and secure Wifi in the parking lot especially for uploading your documents.

Go to your wifi settings and join the Wifi: CMED-CheckIn
with password: CommunityMed

FIRST TAKE PHOTOS of front and back of your form
THEN select below and upload those images.

Upload photo of FRONT of form

Upload photo of BACK of form

We have logged your DOT registration

- Click Next to continue

We have logged your School Physical answers

- Click Next to continue

We have logged your Motor Vehicle Accident answers

- Click Next to continue

We have logged your Work Injury answers

- Click Next to continue

You are done with additional questions - Click next below to continue

This field is hidden when viewing the form

Section Break

St-3 P-11

Head
Face
Neck
Left Shoulder
Right Shoulder
Upper Chest
Upper Back
Left arm
Left Hand/Fingers
Right arm
Right Hand/Fingers
Left ribs
Right ribs
Stomach
Back
Hips
Lower back
Butt
Left Thigh
Right Thigh
Left knee
Right Knee
Left shin
Right Shin
Left ankle
Right ankle
Left foot/toes
Right Foot/toes