Telehealth Clinical Assessment Form
Telehealth Clinical Assessment Form
Please fill in the fields below with accurate details.
Date
Name
Date of Birth
Phone Number
Address
Reason for Visit
Current Symptoms
Select all that apply:
-
Fever
-
Cough
-
Shortness of Breath
-
Fatigue
-
Allergies
Are you dealing with any of the following conditions?
Select all that apply:
-
Diabetes
-
High Blood Pressure
-
Asthma
-
Cancer
-
Heart Disease
-
None
Are you currently taking any medications?
If yes, please specify
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