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REMOTE MEDICAL CONSULTATION

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Patient Information

Full Name
DOB
SS#
Patient Email
Patient Mobile
Patient Address
Country
State
City
Reference Physician Name
Physician Email
Physician Phone
Current Condition/Complications
Allergies Medications
Medicine
Reaction
Date Start
Allergies Others

OFFICE USE ONLY

RUE(BP)mmHg
(Height)inches
LUE(BP)mmHg
(Weight)lbs
(Heart Rate) bpm
(Temp) °F
(Resp. Rate)per/min
(O2 Sat)%
History of Present Illness
Previous Hospital Admissions/Surgeries/Serious Injuries
Date/s
Name of Hospital

Patient Medical History*

  • Diabetes YES NO
  • High Blood Pressure YES NO
  • High Cholesterol YES NO
  • Cancer YES NO
  • Stroke YES NO
  • Heart Issues YES NO
  • Convulsions YES NO
  • Bleeding Tendencies YES NO
  • Recent Infection YES NO
  • Sexually Transmitted Disease YES NO
  • HIV/AIDS YES NO
  • Hepatitis YES NO
  • Tuberculosis YES NO
  • Family History of Cancer YES NO
  • Other History

Patient Social History*

  • Marital Status Single Married Seperated Divorced Widowed
  • Use of Alcohol Never Rarely Moderate Daily
  • Use of Tobacco Never Previously, but quit
  • Current Packs/Day
  • Use of Drugs Never
  • Type Frequncy
  • Travel Outside Country No Yes
  • If yes, where and when?

Family Medical History

Father
Mother
Brother/Sister
Brother/Sister
Brother/Sister
Son/Daughter
Son/Daughter
Son/Daughter
Other Pertinent Family History(Optional)
Other Health Care Providers Involved in Care

Review of Systems

Constitutional System

  • Good General Health Yes No
  • Recent Weight Change Yes No
  • Fever Yes No
  • Fatigue Yes No
  • Headaches Yes No

EYES

  • Eye Disease or Injury Yes No
  • Wear Glasses/Contact Lenses Yes No
  • Blurred or Double Vision Yes No
  • Glaucoma Yes No

EARS/NOSE/THROAT

  • Hearing Loss/Ringing Yes No
  • Chronic Sinus Problems Yes No
  • Nose Bleeds Yes No
  • Bad Breath or Bad Taste Yes No
  • Sore Throat/Voice Change Yes No

CARDIOVASCULAR

  • Heart Problems Yes No
  • Chest Pain or Angina Yes No
  • Palpitations Yes No
  • Shortness or Breath Lying Yes No
  • Swelling of Feet/Ankeles/Legs Yes No
  • Varicose Veins Yes No

RESPIRATORY

  • Chronic Cough Yes No
  • Coughing up Blood Yes No
  • Shortness of Breath Yes No
  • Asthma or Wheezing Yes No

MUSKULOSKELETAL

  • Joint Pain/Stiffness/Swelling Yes No
  • Weakness in Muscles/Joints Yes No
  • Muscle Pain or Cramps Yes No
  • Cold Extremities Yes No
  • Difficulty Walking Yes No

GASTROINTESTINAL

  • Loss of Appetite Yes No
  • Change in Bowel Movements Yes No
  • Painful Bowel Movements Yes No
  • Constipation Yes No
  • Rectal Bleeding/Blood in Stool Yes No
  • Abdomial Pain/Heartburn Yes No
  • Peptic Ulcer Yes No
  • Unable to Restrain Stools Yes No
  • Colon Cancer Yes No
  • Polyps Yes No
  • Nausea or Vomitting Yes No

Have you ever following tests

  • Colonoscopy Yes No
  • Barium Enema Yes No
  • Flexible Sigmoidoscopy Yes No

BLOOD AND LYMPH

  • Slow to Heal After Cuts Yes No
  • Bleeding/Bruising Tendencies Yes No
  • Anemia Yes No
  • Blood Clots Yes No
  • Past Transfusion Yes No
  • Enlarged Glands Yes No
  • Frequent Urination Yes No

URINARY AND REPRODUCTIVE

  • Burning Painful/Urination Yes No
  • Blood in Urine Yes No
  • Unable to Restrain Dribbling Yes No
  • Kidney Stones Yes No
  • Male-Testicle Pain Yes No

FOR FEMALE ONLY

  • Pain with Menstruation Yes No
  • Irregular Menstruation Yes No
  • Vaginal Discharge Yes No
  • Breast Feed Yes No
  • Hysterectomy Yes No
  • Ovaries Removed Yes No
  • Birth Control Yes No
  • Menopause Yes No
  • Age Started Menstruation
  • Last Menstrual Period(date)
  • # of Pregnancies
  • # of Miscarriages
  • # Age of First Pregnancy
  • # of Children
  • Date of Last Pap Smear

SKIN AND BREAST

  • Rash and Itching Yes No
  • Breast Pain or Soreness Yes No
  • Breast Lump Yes No
  • Had Recent Mammogram Yes No
  • Any Previous Breast Surgery Yes No

NEUROLOGICAL

  • Frequent Headaches Yes No
  • Light Headedness or Dizziness Yes No
  • Convulsions or Seizures Yes No
  • Numbness/Tingling Yes No
  • Tremors Yes No
  • Paralysis Yes No
  • Stroke Yes No
  • Head Injury Yes No

ENDOCRINE

  • Gland/Hormone Problem Yes No
  • Thyroid Disease Yes No
  • Diabetes Yes No
  • Excessive Thirst/Urination Yes No
  • Heat or Cold Intolerence Yes No
  • Skin Becoming Drier Yes No

PSYCHIATRIC

  • Memory Loss/Confusion Yes No
  • Nervousness Yes No
  • Depression Yes No
  • Sleeping Problems Yes No

ATTACHMENTS

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