New Visit prescreen

1
Name* This field is required.
Last Name
First Name
2
Email* This field is required.
example@example.com
3
Phone Number
Please enter a valid phone number.
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Date of Birth* This field is required.
Date
Year
Month
Day
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AddressYour address is needed to determine if you can participate in our mobile services.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Please Select
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The Gambia
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Luxembourg
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Madagascar
Malawi
Malaysia
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Mali
Malta
Marshall Islands
Martinique
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Mauritius
Mayotte
Mexico
Micronesia
Moldova
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Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
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Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
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Samoa
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eSwatini
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Tuvalu
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Vatican City
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British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
What is your primary health concern for Today’s visit?* This field is required.Examples: Difficulty concentrating, cannot sleep, constipation
7
Do you currently have positive COVID results or have you been exposed to COVID in the past 2 weeks?* This field is required.
YESNO
8
Are you currently pregnant?* This field is required.***Male clients Select “No”
YESNO
9
First day of Last Period* This field is required.***For male patients type NA
Ex: Jan 1, 2022
10
Have you noticed any of the following symptoms:* This field is required.Increased urination, Pain when urinating, inability to urinate, missed period? (Select yes if you have at least 1 symptom)
YESNO
11
Do you have any known heart conditions? If Yes, please indicate the type of heart condition/ disease you have. * This field is required.Ex. Yes. I have coronary artery disease.
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Ok
Ok
12
Do you have any nerve damage or conditions that affect your nerves?* This field is required.Ex. Yes I have diabetes and Multiple Sclerosis
Huge
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Small
Ok
Ok
13
Do you have intolerance to hot or cold temperatures?* This field is required.Ex.: I am intolerant to cold, it makes me numb.
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Ok
Ok
14
Any new or changing symptoms? If yes, please explain. * This field is required.Ex: “Yes. I have a rash that started yesterday. It’s red, bumpy, and has a gray discoloration at the center. I also have a fever and chills.”
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Ok
15
Rate your Stress on a scale of 0-10:* This field is required.0= No stress 😎 , 10= Unbearable Stress 😫
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1. Do you have any pain? 2. If yes where? 3. Rate pain from 0 to 10. 4. How long does it last? 5. Does it travel to other places?* This field is required.Scale: 0= no pain😁, 10=unbearable pain😭
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Ok
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Describe your mood:* This field is required.Ex.: I’m upset, having issues with my coworker.
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Rate your energy level on a scale of 0-10.* This field is required.Scale: 0= No energy 🥱, 10= Most energy 😁
19
List the foods you ate in the last 24hrs. * This field is required.Indicate whether it was for breakfast (5am-10am), lunch (11am-3pm), or dinner (4pm or later)
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Ok
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When was your last meal?* This field is required.
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Hour
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Minutes
PM
AM
PM
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How has your bowel movements been?* This field is required.Ex: I’ve had regular bowel movements, brown, shaped like a nugget, easy to pass, twice per day, no blood or undigested food.
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Ok
Ok
22
How has your sleep been in the past week.* This field is required.Ex.: I have not had restful sleep. I go to bed a 7 and wake up at 9am and cannot get enough sleep.
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Ok
23
Have you experienced stress at work or home. * This field is required.Ex.:Yes. I have a big project coming up.
24
Are you currently taking any medications or natural supplements?* This field is required.***If yes, list 1. The name of the product or medication, 2. The dose that you take, 3. How often you take it and 4. How frequently typing take it.
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Ok
25
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Today’s Date* This field is required.
Date
Year
Month
Day
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