Skip to content
Home
99-5-1 What is wrong today?
CMed Triage – Health Background
This field is hidden when viewing the form
Email added to delete personal info
Medical History and Triage
Please answer or confirm your previous answers to these medical screening questions
This field is hidden when viewing the form
Traffic Source
This field is hidden when viewing the form
Decimal Time
This field is hidden when viewing the form
Date
MM slash DD slash YYYY
This field is hidden when viewing the form
Visit ID
This field is hidden when viewing the form
Pull Data
– Fill Out Other Fields –
This field is hidden when viewing the form
Patient ID
This field is hidden when viewing the form
Clinic ID
This field is hidden when viewing the form
Reason Visit Category
This field is hidden when viewing the form
Patient Name
First
Last
This field is hidden when viewing the form
Patient Phone
This field is hidden when viewing the form
Clinic Name
This field is hidden when viewing the form
Patient Sex
Reason for Todays Visit
This field is hidden when viewing the form
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
This field is hidden when viewing the form
Preferred Pharmacy
First Choice
Second Choice
Third Choice
This field is hidden when viewing the form
Visit Preferred Pharmacy
This field is hidden when viewing the form
Patient Preferred Pharmacy
This field is hidden when viewing the form
Primary Care Doctor
First Choice
Second Choice
Third Choice
This field is hidden when viewing the form
Primary Care Doctor
This field is hidden when viewing the form
Already completed
– Fill Out Other Fields –
This field is hidden when viewing the form
Date of completed hlth record
MM slash DD slash YYYY
This field is hidden when viewing the form
Already_Completed
We show you have already completed a medical history previously
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)
