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Patient DOB Date
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Patient Name
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Last
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Patient Mobile
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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.
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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
No
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
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Where on the car did it hit?
Front bumper
Driver side
Passenger side
Rear bumper
Other
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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
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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
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YYYY
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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
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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
No
Does the patient have their eScreen form with barcode
Yes
No
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
Driver's License
Employer ID
Health ID
Military ID
Passport ID
Other
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
:
AM
PM
AM/PM
Did you report the injury to your employer?
Yes
No
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
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
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
No
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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
No
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
No
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
No
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
No
Is it likely that your child need eye glasses to pass an eye exam at 20/40
(Required)
Yes
No
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
No
Has a physician ever denied or restricted child's participation in activities for any heart problems?
(Required)
Yes
No
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
No
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.
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St-3 P-5
DOT Physical
Verification of Driver's Identity By:
Drivers License
Military ID
Employer ID
Health ID
Passport ID
Other
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)
New Certification
Re certification
Follow Up
Driver's License State
(Required)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Commercial Driver's License Number
(Required)
Has your USDOT/FMCSA medical certificate ever been denied or issued for less than 2 years?
Yes
No
Not Sure
Do you have a recent history or have you been diagnosed with high blood pressure?
(Required)
yes
no
WITH YOU TODAY - Do you have Do you have an active prescription to control your high blood pressure?
(Required)
yes
no
Not Applicable
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Hidden HBP uncontrolled
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St-3 P-6
Do you have a recent history or have you been diagnosed with Diabetes?
(Required)
yes
no
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
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Hidden Diabetes uncontrolled
Do you use a CPAP machine?
(Required)
Yes
No
Do you have documentation WITH YOU TODAY of proper use of the machine over the past 90 days?
(Required)
Yes
No
Sometimes the machine has an app or web history.
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Hidden cpap uncontrolled
Do you have a history of a stroke, seizure disorder, brain tumor, or bleeding in the brain?
(Required)
yes
no
WITH YOU TODAY - do you have a release letter from your Neurologist including documentation of any medications
(Required)
Yes
No
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Hidden neuro uncontrolled
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Do you have a recent history or diagnosis of heart related medical issues?
(Required)
yes
no
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
no
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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
no
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
no
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Hidden medication uncontrolled
Have you permanently lost use of any limb
(Required)
yes
no
WITH YOU TODAY - do you have a note from a medical provider describing the injury and any required work restrictions
(Required)
yes
no
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Hidden lost limb uncontrolled
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St-2 P-8
Are you currently taking blood thinners?
(Required)
yes
no
WITH YOU TODAY - do you have documentation from a medical provider indicating you INR (Internationalized-normalized ratio)
(Required)
Yes
No
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Hidden INR uncontrolled
What is your height: FEET
(Required)
INCHES
(Required)
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What is your height in inches
What is your weight in lbs
(Required)
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Calculated BMI
WITH YOU TODAY - do you have a documented sleep study
(Required)
yes
no
Your BMI was over the 40 threshold requiring a sleep study to release you for DOT
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Hidden sleep study uncontrolled
Do you wear corrective lenses or contact lenses or hearing aids?
(Required)
yes
no
Do you have those lenses/glasses or hearing aid with you today for the exam?
(Required)
yes
no
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Hidden lenses aid uncontrolled
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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.
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St-3 P-9
HIDDEN clinc reg email
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payment method
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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
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Date Completed
MM slash DD slash YYYY
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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
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Total Score
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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
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St-3 P-11
