Please enable JavaScript in your browser to complete this form.Patient Name *FirstLastPatient Date of Birth (DOB) *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Do You Have Email Confirmed Appointment Date and Time? *YesNoBest Date & Best Time to Schedule VisitDateTimeBest Date and Time to schedule your visit with Frontline MDs. Chief Complaint: *What is your reason for this visit.Source: *PatientSpouseGuardianOtherOtherPMH Section I: *- Select Here -PMH Section I: HX (History)PMH Section I: Select HX (History)Past HX: *AsthmaCVACV DiseaseCOPDDiabetesEmphysemaHigh CholesterolKidney DiseaseLiver DiseaseLung DiseaseMI, HFNeurological ProblemsNon ContributorySeizuresOther/Unlisted Medical ConditionN/APast 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): *AsthmaCVACV DiseaseCOPDDiabetesEmphysemaHigh CholesterolKidney DiseaseLiver DiseaseLung DiseaseMI, HFNeurological ProblemsNon ContributorySeizuresN/AFamily History: PaternalFamily HX (M) *AsthmaCVACV DiseaseCOPDDiabetesEmphysemaHigh CholesterolKidney DiseaseLiver DiseaseLung DiseaseMI, HFNeurological ProblemsNon ContributorySeizuresN/AFamily History: MaternalFamily HX: NotesSocial HX: *AlcoholDrugsTobaccoIf None Apply Select Each And Type N/ASocial HX Note: AlcoholHow many Drink(s) per Day?Social HX Note: DrugsHow Many Times per Day?Social HX Note: TobaccoHow Much Tobacco per Day (approx.)PMH Section I: Did You Select HX (History)? *NOYesPMH Section II: *- Select Here -MEDS (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? *NOYesPMH Section III: Current Condition- Select Here -PMH Section III: Current Condition or Vitals (Optional)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:Submit Please enable JavaScript in your browser to complete this form.Patient Name: *FirstMiddleLastDate of Birth (DOB): *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age: Selected Value: 0 SSN (Social Security #):Chief Complaint:Source:PatientSpouseGuardianOtherVisit Date:Visit Start Time:Other Notes:Provider Notes (PNx) for: *General IllnessCOVID ProtocolEMR Sections I: *- Select Here -HPI (Section I)Onset:AcuteChronicEpisodicRecurrentN/ASeverity:MildModerateSevereN/AOnset/Severity Notes:Assoc. SX:Similar PreviouslyRecently TreatedMedsN/AAssoc. SX Notes:EMR Sections II:- Select Here -ROS (Section II)EMR Sections II: COVID Protocol *- Select Here -ROS (Section II)Non-Contributory:CONST:ChillsFatigueFeverNight SweatsWeight GainWeight LossN/AOtherOther: CONSTCOVID Protocol: ROSFeverChillsHeadacheNasal CongestionSore ThroatCoughShortness of BreathChest DiscomfortNauseaVomitingDiarrheaAbdominal PainTirednessFatigueBody AcheJoint PainSleeplessnessRashNAOtherOther: ROSENT:Changing VoicesEpistaxisNasal Drainage, CongestionOral LesionsSinus PressureSore ThroatOtherN/AOther: ENTCHEST:CoughHemoptysisShortness of Breath (Dyspnea)Sputum ProductionN/ACV:Chest PainHeart MurmurHeart PalpitationsLeg SwellingPeripheral PulsesRightLeftN/AOtherOther: CVGI:Abdominal PainBlood In-StoolConstipationDiarrheaHeartburnHematocheziaMelenaNauseaSaundiceRectal BleedingRectal PainVomitingN/AOtherOther: GIUrinary:DischargeDysparcuniaDysuriaFlank PainHematuriaHesitancyHistory of STIFrequencyProblems UrinatingResidualSTI ExposureTesticular PainUrinary IncontinenceN/AOtherOther: UrinaryFemale Genital:DischargeDysparcuniaHistory of STILNMP - Postmenopause, PosthysterectomyOdorVaginal BleedingVaginal DisorderSTI ExposureN/AOtherOther: Female GenitalSkin:AbrasionAbscessCyanosisItchingPallorRashN/AOtherOther: SkinMusculoskeletal:Back PainCalf Tenderness (L)Calf Tenderness (R)Foot Swelling (L)Foot Swelling (R)Joint PainLeg Pain (R)Leg Pain (L)TendernessWeaknessN/AOtherMusculoskeletal: OtherMusculoskeletal Cont:ArmLegFaceNAArm:Weak (R)Weak (L)Numb (R)Numb (L)N/ALeg:Weak (R)Weak (L)Numb (R)Numb (L)N/AFace:Weak (R)Weak (L)Numb (R)Numb (L)N/AEyes:ConjuctivitisBlurred VisionBlephartis (L)Blephartis (R)Decreased Visual Activity - DistanceDecreased Visual Activity - NearDiplopiaDouble VisionEye PainEye RednessVision ChangesN/AOther: Musculoskeletal ContNeuro/PsychAbdominal GaitConfusionDepressedDysarthriaDysphagiaFiat AffectHeadacheNumbnessTinglingN/AOtherOther: Neuro/PsychDisorientationTimePersonPlaceN/AOtherOther: DisorientationROS Notes:EMR Sections III:- Select Here -HX (Section III)EMR Sections III: COVID Protocol *- Select Here -HX (Section III)Past HX: *AsthmaCVACV DiseaseCOPDDiabetesEmphysemaHigh CholesterolKidney DiseaseLiver DiseaseLung DiseaseMI, HFNeurological ProblemsNon ContributorySeizuresOtherNAPast HX: OtherHX: COVID Protocol *Irregular HeartbeatCongestive Heart FailurePacemakerDiabetesHigh Blood PressureCOPDAsthmaEmphysemaLiver DiseaseAcid RefluxKidney DiseasePsoriasisDizzinessVertigoAnxietyDepressionOtherNAOther:Past HX Note:Social HXAlcoholDrugsTobaccoSocial HX Note:Family HX:EMR Sections IV:- Select Here -MEDS (Section IV)OTC Meds:Prescription Meds:Allergies:Meds Notes:EMR Sections V:- Select Here -Section V: PHYSICAL EXAM (VITALS)BP:Pulse:Temp:HR:Resp/Rate:Clinical Impression:Discharge Meds/Plan:Disposition:HomeAdmittedReferredFollow-Up:Personal PhysReturn to ClinicReferred PhysVisit End Time:Frontline MDs Indentification #Provider Title: *- Select Here -MDPAPRNDPhPAAFrontline MDs Providers Name *Provider Authorized Administrator Name *Provider Signature *Clear SignatureOr Provider Authorized AdministratorClose Notes