Today's date
Name
First Name
Last Name
Date of birth
Phone Number
-
Area Code
Phone Number
E-mail address
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Height
for Children
Weight
for Children
Drug allergies
Do you see a Primary Care Physician?
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-- Please Select --
Yes
No
If yes, please list name of physician.
When did the symptoms begin?
Symptoms
Body aches
Diarrhea
Fever greater than 100.4 F
Nausea
Sore Throat
Stuffy Nose
Tiredness
Vomiting
Cough
Other
List any conditions below that you being currently treated for:
Have you received a flu vaccine?
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-- Please Select --
Yes
No
If yes, when was the last vaccination?
Did you take something like Tylenol (acetaminophen), Aleve (naproxen), or Motrin/Advil (ibuprofen) before you came to the clinic?
Please Select
-- Please Select --
Yes
No
If yes, what did you take (type/amount)?
If yes, when did you last take the medication?
Enter name for consent:
*
Appointment
Select Testing Service
Rapid Strep Test
Rapid Covid Antigen Test
Rapid Flu A+B Antigen Test
Rapid Combo Test (Flu A, Flu B, & Covid)
Submit Form
Office Use Only
Rows
Value
Temperature
Blood Pressure
Pulse Ox
Tonsillopharyngeal inflammation
Patchy tonsillopharyngeal exudates
Palatal petechiae
Anterior cervical adenitis
Office Use Only
Rows
Result
Flu A
Flu B
SARS COVID
Strep A
Office Use Only (Strep A Treatment)
Rows
Verify Treatment
Amoxicilin 25mg/kg (max 500mg) PO BID x10d
Cephalexin 20mg/kg/dose (max 500mg/dose) PO BID x10d
Azithromycin 12mg/kg (max 500mg) PO QD x5d
Clindamycin 7mg/kg/dose (max 300mg/dose) PO TID x10d
Clarithromycin 7.5mg/kg/dose (max 250mg/dpse_ PO BID x10d
Office Use Only (Influenza Treatment)
Rows
Verify Treatment
Olseltamivir: Adults: 75mg BID x5d;
Olseltamivir: Children: 15kg or less (30mg BID); >15 to 23kg (45mg BID); >23 to 40kg (60mg BID); >40kg (75kg BID)
Zanamivir: Adults: 10mg (two 5mg inhalations) BID x5d
Zanamivir: Children (7 years or older) - 10mg (two 5mg inhalations) BID x5d
Oral Baloxavir (7 years or older): 20mg or 40mg one-time dose
Should be Empty: