Test | Frontline MDs

Patient Name *

First

Last

Patient Date of Birth (DOB) *//

Do You Have Email Confirmed Appointment Date and Time? *

Best Date & Best Time to Schedule Visit

Date

Time

Best Date and Time to schedule your visit with Frontline MDs.

Chief Complaint: *

What is your reason for this visit.

Source: *

Patient
Spouse
Guardian
Other

Other

PMH Section I: *

PMH Section I: Select HX (History)

Past HX: *

Asthma
CVA
CV Disease
COPD
Diabetes
Emphysema
High Cholesterol
Kidney Disease
Liver Disease
Lung Disease
MI, HF
Neurological Problems
Non Contributory
Seizures
Other/Unlisted Medical Condition
N/A

Past HX Notes:

Please inform Frontline MDs provider of any additional information concerning Past HX here.

Past HX: Other/Unlisted Medical Condition *

Please inform Frontline MDs provider of any other or unlisted medical conditions here.

Family HX (P): *

Asthma
CVA
CV Disease
COPD
Diabetes
Emphysema
High Cholesterol
Kidney Disease
Liver Disease
Lung Disease
MI, HF
Neurological Problems
Non Contributory
Seizures
N/A

Family History: Paternal

Family HX (M) *

Asthma
CVA
CV Disease
COPD
Diabetes
Emphysema
High Cholesterol
Kidney Disease
Liver Disease
Lung Disease
MI, HF
Neurological Problems
Non Contributory
Seizures
N/A

Family History: Maternal

Family HX: Notes

Social HX: *

Alcohol
Drugs
Tobacco

If None Apply Select Each And Type N/A

Social HX Note: Alcohol

How many Drink(s) per Day?

Social HX Note: Drugs

How Many Times per Day?

Social HX Note: Tobacco

How Much Tobacco per Day (approx.)

PMH Section I: Did You Select HX (History)? *

PMH Section II: *

Section I and Section II required.

OTC Meds: *

List All Over-The-Counter Medications or Vitamins Here. If none type None or NA.

Prescription Meds: *

List All Current Prescription Medications Here. If none type None or NA.

Allergies: *

List All Allergies Here. If none type None or NA.

Meds Notes:

Any additional notes or comments for Frontline MDs provider?

PMH Section II: Did You Select MEDS? *

PMH Section III: Current Condition

If you have the home devices necessary to help Frontline MDs provider give best possible medical information please include here.

Blood Pressure:

Pulse:

Temperature:

Heart Rate:

Resp/Rate:

Patient Name: *

First

Middle

Last

Date of Birth (DOB): *//

Age:

Selected Value: 0

SSN (Social Security #):

Chief Complaint:

Source:

Patient
Spouse
Guardian
Other

Visit Date:

Visit Start Time:

Other Notes:

Provider Notes (PNx) for: *

General Illness
COVID Protocol

EMR Sections I: *

Onset:

Acute
Chronic
Episodic
Recurrent
N/A

Severity:

Mild
Moderate
Severe
N/A

Onset/Severity Notes:

Assoc. SX:

Similar Previously
Recently Treated
Meds
N/A

Assoc. SX Notes:

EMR Sections II:

EMR Sections II: COVID Protocol *

Non-Contributory:

CONST:

Chills
Fatigue
Fever
Night Sweats
Weight Gain
Weight Loss
N/A
Other

Other: CONST

COVID Protocol: ROS

Fever
Chills
Headache
Nasal Congestion
Sore Throat
Cough
Shortness of Breath
Chest Discomfort
Nausea
Vomiting
Diarrhea
Abdominal Pain
Tiredness
Fatigue
Body Ache
Joint Pain
Sleeplessness
Rash
NA
Other

Other: ROS

ENT:

Changing Voices
Epistaxis
Nasal Drainage, Congestion
Oral Lesions
Sinus Pressure
Sore Throat
Other
N/A

Other: ENT

CHEST:

Cough
Hemoptysis
Shortness of Breath (Dyspnea)
Sputum Production
N/A

CV:

Chest Pain
Heart Murmur
Heart Palpitations
Leg Swelling
Peripheral Pulses
Right
Left
N/A
Other

Other: CV

GI:

Abdominal Pain
Blood In-Stool
Constipation
Diarrhea
Heartburn
Hematochezia
Melena
Nausea
Saundice
Rectal Bleeding
Rectal Pain
Vomiting
N/A
Other

Other: GI

Urinary:

Discharge
Dysparcunia
Dysuria
Flank Pain
Hematuria
Hesitancy
History of STI
Frequency
Problems Urinating
Residual
STI Exposure
Testicular Pain
Urinary Incontinence
N/A
Other

Other: Urinary

Female Genital:

Discharge
Dysparcunia
History of STI
LNMP - Postmenopause, Posthysterectomy
Odor
Vaginal Bleeding
Vaginal Disorder
STI Exposure
N/A
Other

Other: Female Genital

Skin:

Abrasion
Abscess
Cyanosis
Itching
Pallor
Rash
N/A
Other

Other: Skin

Musculoskeletal:

Back Pain
Calf Tenderness (L)
Calf Tenderness (R)
Foot Swelling (L)
Foot Swelling (R)
Joint Pain
Leg Pain (R)
Leg Pain (L)
Tenderness
Weakness
N/A
Other

Musculoskeletal: Other

Musculoskeletal Cont:

Arm
Leg
Face
NA

Arm:

Weak (R)
Weak (L)
Numb (R)
Numb (L)
N/A

Leg:

Weak (R)
Weak (L)
Numb (R)
Numb (L)
N/A

Face:

Weak (R)
Weak (L)
Numb (R)
Numb (L)
N/A

Eyes:

Conjuctivitis
Blurred Vision
Blephartis (L)
Blephartis (R)
Decreased Visual Activity - Distance
Decreased Visual Activity - Near
Diplopia
Double Vision
Eye Pain
Eye Redness
Vision Changes
N/A

Other: Musculoskeletal Cont

Neuro/Psych

Abdominal Gait
Confusion
Depressed
Dysarthria
Dysphagia
Fiat Affect
Headache
Numbness
Tingling
N/A
Other

Other: Neuro/Psych

Disorientation

Time
Person
Place
N/A
Other

Other: Disorientation

ROS Notes:

EMR Sections III:

EMR Sections III: COVID Protocol *

Past HX: *

Asthma
CVA
CV Disease
COPD
Diabetes
Emphysema
High Cholesterol
Kidney Disease
Liver Disease
Lung Disease
MI, HF
Neurological Problems
Non Contributory
Seizures
Other
NA

Past HX: Other

HX: COVID Protocol *

Irregular Heartbeat
Congestive Heart Failure
Pacemaker
Diabetes
High Blood Pressure
COPD
Asthma
Emphysema
Liver Disease
Acid Reflux
Kidney Disease
Psoriasis
Dizziness
Vertigo
Anxiety
Depression
Other
NA

Other:

Past HX Note:

Social HX

Alcohol
Drugs
Tobacco

Social HX Note:

Family HX:

EMR Sections IV:

OTC Meds:

Prescription Meds:

Allergies:

Meds Notes:

EMR Sections V:

BP:

Pulse:

Temp:

HR:

Resp/Rate:

Clinical Impression:

Discharge Meds/Plan:

Disposition:

Home
Admitted
Referred

Follow-Up:

Personal Phys
Return to Clinic
Referred Phys

Visit End Time:

Frontline MDs Indentification #

Provider Title: *

Frontline MDs Providers Name *

Provider Authorized Administrator Name *

Provider Signature *

Or Provider Authorized Administrator