Telemedicine Consultant Evaluation

PRE-CONSULTATION SCREENING FORM
DEMOGRAPHICS

Patient Information
Patient Name

First NameLast Name
ID Number
Sex/Gender

Other
Marital Status

Other
Email
example@example.com
Phone Number

Area CodePhone Number
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Weight (kg)
Height (m)
What is the purpose of the appointment?

Other
JOB DESCRIPTION

Occupation and physical demands of the job
Employment Tittle/Occupation
e.g. unemployed, teacher, lecturer, attorney, constable, store manager, taxi driver, etc...
Work activity level (frequent postural loading position)
Travel frequency for work
MEDICAL and INJURY HISTORY

Any other health conditions and previous injuries
Where is the main injury/complaint? (Knee, lower back, bum, shoulder, upper back etc...)
Most current and painful area
The injured side
Pain or injury location
e.g. Neck, upper back, shoulder, lower back, hip, knee, ankle etc...

Please rate your current pain level.

	1	2	3	4	5

1 is Mild, 5 is Severe

How did it happen? Describe scenario leading up to the injury.
e.g. Fell down the stairs, felt when running, car accident, playing soccer etc...
Pain duration

Other
Movements and activities that provokes the pain
e.g. prolonged seating, walking, running, prolonged standing, climbing the stairs, lying on the affected side etc...
Please list any previous injuries and operations below .
e.g. Right Knee replacement, left shoulder injury, right femur fracture due to car accident etc...
Have you been told by a doctor not to exercise in the last 6 months?
Are you pregnant?
Are you a current smoker?
Do you currently participate regularly in exercise for at least 30 minutes (3 days per week)?
Do you suffer from any chronic conditions for which you are taking medication?
Select all that apply.

Other

Please state your determination for recovery.

	1	2	3	4	5

1 is Discouraged , 5 is Very determined

Referred Patient - select all that apply

Other
Medical Aid Name
e.2g. medical aid, private patient
Referring Individual's name
e.g. Dr Lebea, Precious Lebea, Coach Lebea
PAYMENT METHOD

Kindly note that you'll be liable for financial cost if there are no funds on your medical claims.
Payment method
e.g. medical aid, private patient
Medical Aid Option Plan
e.2g. medical aid, private patient
Medical Aid Number
e.2g. medical aid, private patient
Dependent Number
e.2g. medical aid, private patient
Additional Comments
Next of Kin/Emergency Contact

Fill in details of the individual to contact in case of an emergency.
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Relationship
e.g. Patient's husband, wife, mother, father, brother, sister, uncle, etc.
Patient Signature
Date

YearMonthDay
4 digit year, 2 digit month, 2 digit dayDate
Should be Empty:

PRE-CONSULTATION SCREENING FORM