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99-5-1 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
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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Clinic ID
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Reason Visit Category
Patient Name
First
Last
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Patient Phone
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Clinic Name
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Patient Sex
Reason for Todays Visit
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Reason for coming in today
Date Symptoms Started
(Required)
MM slash DD slash YYYY
Injury Date
(Required)
MM slash DD slash YYYY
How severe are your illness symptoms
(Required)
(1 is mild, 10 is worst)
1
2
3
4
5
6
7
8
9
10
How severe is your injury
(Required)
(1 is mild, 10 is worst)
1
2
3
4
5
6
7
8
9
10
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Preferred Pharmacy
First Choice
Second Choice
Third Choice
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Preferred Pharmacy
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Primary Care Doctor
First Choice
Second Choice
Third Choice
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Primary Care Doctor
Are you allergic to any of these medications/medical supplies
(Required)
Check all that apply
No Allergies to Medications
Penicillin/Amoxicillin
Cephalosporins/Cefdinir
Sulfa
Azithromycin/Clindamycin
Lidocaine
Latex
NSAIDs
Other
Other allergies
(Required)
How many medications do you currently take on a routine basis?
(Required)
Please enter a number from
0
to
99
.
Over the counter and prescription
Check here if you have a paper list to provide instead
I have a paper list
Medication 1
(Required)
Medication 2
(Required)
Medication 3
(Required)
List Medications
(Required)
Select the Medical Conditions you have
(Required)
Check all that apply
None
High blood pressure
Diabetes
High cholesterol
Thyroid disorder
Heart disease
Asthma
Anxiety/Depression
ADHD/ADD
Acid Reflux/GERD
Other
Other medical condition
Father medical history
(Required)
Check all that apply
None listed below or Unknown
High blood pressure
Diabetes
High cholesterol
Cancer
Mother medical history
(Required)
Check all that apply
None listed below or Unknown
High blood pressure
Diabetes
High cholesterol
Cancer
Have you had any of the following past surgeries
(Required)
None listed below
Tonsils
Gallbladder
Appendix
Gastric band
Heart bypass
Thyroid
Female Patients – Select One
(Required)
Never had period
Number of weeks since last period
Pregnant
Menopause
Hysterectomy
Weeks since last period
(Required)
Due Date
(Required)
MM slash DD slash YYYY
Do you drink Alcohol
(Required)
Yes
No
Approximate Alcohol Consumption
(Required)
Rare (2 or less drinks per week)
Occasional (3-6 drinks per week)
3+ drinks per day
Tobacco Usage
(Required)
Yes
No
Tobacco Consumption
(Required)
Select all that apply
Cigarette
E-cig/Vape
Cigar
Smokeless (e.g. Dip, Snuff, Chew)
How often do you use tobacco
Daily
Occasional (2-5 times per week)
Rare (1 time per week or less)
