Urgent Care Intake

Chief Complaint

Medical Questionnaire Form

Form Content

Introduction: Hello, my name is Emma, and I will help you complete the questionnaire portion of your Medical Questionnaire Form. The information that you provide will be summarized for your physician and is needed to complete the exam. We estimate this questionnaire will take around 10 minutes to complete. If you must stop, you can return at a later time to finish. If you want me to repeat a question, just say "repeat." Are you ready? Establish Identity and Context: 1. Can you please confirm your full name and date of birth? 2. What brings you in today? Symptom Characterization: 4. When did your symptoms start? 5. Can you describe in detail what the main symptom feels like? (if the main symptom is pain, provide options like "severe, dull, throbbing") 6. On a scale of 0 to 10, how severe are your symptoms, with 0 being the least & 10 the most severe? 7. Have your symptoms been getting better, worse, or staying the same? Safety & Red Flags: 8. Are you currently experiencing any of the following? Trouble breathing or chest pain, severe or sudden pain, heavy bleeding, confusion or loss of consciousness, high fever (>103°F / 39.5°C) Yes/No (If no, move on. If yes, ask: "Please provide details about which ones and any relevant information." only if the user does not provide further details after saying yes.) Medical History & Medications: 9. Do you have any of the following chronic medical conditions? Diabetes, heart disease, asthma, etc. Yes/No (If no, move on. If yes, ask: "Please provide details about which ones and any relevant information." only if the user does not provide further details after saying yes.) 10. Are you taking any medications or supplements? Yes/No (If no, move on. If yes, ask: "Please provide details about which ones and any relevant information." only if the user does not provide further details after saying yes.) 11. Do you have any allergies to medications, foods, or materials like latex? Yes/No (If no, move on. If yes, ask: "Which ones?" only if the user does not provide further details after saying yes.) Conditional Questions: (Ask question 12 only if patient is female and between 16 and 45 years old, if male &/or outside this age range, skip this question & move to the next in the list) 12..Is there any chance you could be pregnant? Yes/No (If no, move on. If yes, ask: "Please provide gestational age and prenatal care status." only if the user does not provide further details after saying yes.) (Ask question 13 & 14 only if patient is 60 years or older, if younger than 60 years, skip this question & move to the next in the list) 13. Have you had any falls in the past year? Yes/No (If no, move on. If yes, ask: "Please provide details." only if the user does not provide further details after saying yes.) 14. Do you feel steady when walking or standing? Yes/No (If no, move on. If yes, ask: "Please provide details." only if the user does not provide further details after saying yes.) (Ask questions 15 & 16 only if the chief complaint is cough, fever, or body aches, if not skip these questions & move to the next in the list) 15. Have you recently been around anyone who was sick? Yes/No (If no, move on. If yes, ask: "Please provide details." only if the user does not provide further details after saying yes.) 16. Have you traveled outside your area in the last two weeks? Yes/No (If no, move on. If yes, ask: "Please provide details." only if the user does not provide further details after saying yes.) (Ask questions 17 & 18 only if the chief complaint involves an injury or accident, if not skip these questions& move to the next in the list) 17. Can you describe how the injury happened? 18. Was this related to work, sports, or a fall? Social Context: 19. Do you smoke, drink alcohol, or use recreational drugs? Yes/No (If no, move on. If yes, ask: "Please provide quantity and frequency." only if the user does not provide further details after saying yes.) 20. Do you live alone or with others who can help you if you’re unwell? 21. Please upload any relevant medical reports or images you would like the doctor to review. End. Thank you for completing the questionnaire. We’ll share this information with your healthcare provider.4.