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Columbus, OH | Integrative Osteopathic Primary Care

Telemed Pre-Visit Form

Please do NOT complete this form unless you have already been scheduled for a Telemed visit. IF you have an upcoming Telemed appointment this form is REQUIRED at least 4 hours before the appointment time. Failure to complete and submit this form may result in our cancelling your appointment.

Overview

Patient Name *

First Name

Last Name

Patient Date of Birth *

Name of Accompanying Adult *

First Name

Last Name

Relation to Patient/Child *

Symptom Description

What is your main symptom of concern today (in 1-2 words)? *

(i.e.: “constipation”, “cough”, “behavior problems”, “ADHD”, etc. All visits need a medical reason, it cannot be “go over labs”, “recheck”, or “med check”.):

If the problem is physical, where is it located?

(i.e. right big toe, left eye, etc.)

When did the problem start?

Was there a triggering event/something you can identify that may have caused the problem?

Please choose a few words to describe the quality of the problem:

Sharp

Dull

Aching

Pressure

Does anything make the problem worse? If so, what?

(i.e. physical activity)

Does anything help the problem get better? If so, what?

(i.e. rest, specific medication, etc.)

Are there other things you have tried to relieve the problem that have not helped? If so, please describe:

Please rate the severity of the symptoms:

Pain Scale:

(1 being the best, and 10 being the worst)

Vitals (Please measure and report any vitals you can!)

Temperature and collection method

(i.e. oral, rectal, axillary)

Weight *

(Please include pounds and ounces if applicable.)

Other vitals:

(i.e. blood pressure, heart rate, O2 saturation, etc.)

Current pharmacy

(Name and location)

Current prescription medications, supplements/vitamins & corresponding dosages:

Review of Systems

Constitutional:

Excess weight loss

Loss of appetite

Fever

Diminished activity

Fatigue

Fussy

Excess weight gain

Eyes:

Blurry vision

Eye redness

Eye itchiness

Eye discharge

Poor eye contact

Eye swelling

Eye pain

ENMT:

(Ear, Nose, Mouth, Throat)

Ear discharge

Clearing throat

Hearing loss

Drooling

Facial swelling

Congestion

Hoarseness

Mouth lesions

Foul-smelling breath

Ear pain

Sneezing

Sinus pressure

Sore throat

Runny nose

Cardiovascular:

Rapid heart rate

Rib pain

Lightheadedness

Chest pain

Breasts:

Lumps

Tenderness

Respiratory:

Cough

Bark-like cough

Wheezing

Chest tightness

Noisy breathing

Rapid respirations

Difficulty breathing

Pain with respiration

Belly breathing

Chest pulling

GI:

(Gastrointestinal)

Difficulty swallowing

Abdominal pain

Diarrhea

Blood in stools

Nausea

Vomiting

Large hard stools

Mucus in stool

Pain with stooling

Not stooling daily

Small pellet stools

GU General:

(Genitourinary)

Blood in urine

Frequency

Bedwetting/accidents

Discharge

GU Female:

(Genitourinary)

Vaginal discharge

Abnormal menses

Musculoskeletal:

Joint swelling

Limited motion

Hypertonia

Swelling

Hypotonia

Trauma

Skin:

Pain

Itchiness

Dry Skin

Redness

Rash

Diaper rash

Skin growths

Skin lumps

Bruising

Eczema worse than usual

Flaking

Hives

Insect bites

Chronic eczema

Neuro:

Weakness

Tingling

Burning

Numbness

Shooting pain

Loss of consciousness

Headache

Dizziness

Psych:

Anxiety

Stress

Loss of interest

Mood instability

Depression

Tantrums

Meltdowns

Endocrine:

Increased drinking

Sleep:

Crying

Nightmares

Difficulty falling asleep

Waking at night

Won't sleep alone

Enuresis

Please include any additional information or questions for the practitioner.

After you complete this form, select "SUBMIT" below.

Then refer to the invite we included in your email. Join the zoom meeting 5 minutes before your appointment time to ensure no technical issues. You want to get to the screen that says "Waiting for Host".

Thank you!

Carine Pediatrics

3300 Riverside Drive #200,

Upper Arlington, OH, 43221,

United States

614.459.4200 mail@drcarine.com

Hours

Mon 7am - 7pm

Tue 7am - 7pm

Wed 7am - 7pm

Thu 7am - 7pm

Fri 7am - 5pm

Schedule an Appointment | Patient Portal |Supplement Store

(614) 459-4200 • 3300 Riverside Dr. #200, Upper Arlington, OH 43221

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