Influenza/Strep Patient Information (Under 18)
Today's Date:
Name
Date of Birth
/
Month
/
Day
Year
Date
Age
Gender
Email
example@example.com
Phone
Address
Address
Street Address Line 2
City
State
Zip
Primary Care Provider
Primary Care Phone
What test are you looking to receive today?
Influenza
Strep
Both influenza and strep
1. Are you younger than 6 years of age?
Yes
No
2. Are you pregnant or breastfeeding?
Yes
No
3. Are you experiencing any altered mental status or change from normal cognition?
Yes
No
If yes, please explain
4. Have you ever been diagnosed with a weakened immune system? (e.g., cancer, HIV/AIDS, transplant long term steroids, etc.)
Yes
No
5. Do you have a history of rheumatic fever, rheumatic heart disease, scarlet fever?
Yes
No
6. Do you require supplemental oxygen?
Yes
No
7. Are you receiving hemodialysis?
Yes
No
8. Do you have a history of chronic kidney disease or reduced kidney function?
Yes
No
9. Have you tested positive for an upper respiratory infection in the previous four weeks?
Yes
No
10. If you answered "Yes" to question 9, have you been tested somewhere else and are awaiting those results?
Yes
No
11. Have you had your tonsils removed within the last 30 days?
Yes
No
12. How long have your symptoms been present?
0-24 hours
24-48 hours
48-96 hours
Longer than 96 hours
13. Do you have a history of allergic reaction to influenza or strep treatments, history of physiologic side effects from any previous influenza or strep treatments? Have you received FluMist or a generic equivalent vaccine within the past two weeks?
Yes
No
If you answered yes to the above, please explain
14. Do you have any of the following symptoms?
Fever
Sore throat
Nasal congestion
Pain when swallowing
Muscle or body aches
Red and swollen tonsils and/or lymph nodes
Cough
Other
If you selected fever in question 14, has it reached greater than 102 degrees Fahrenheit (temporal), 103 degrees Fahrenheit (oral), 104 degrees Fahrenheit (tympanic), or has been less than 96.8 degrees Fahrenheit?
Yes
No
If you have answered "Yes" to any questions 1-11, have selected "yes" regarding fever temperatures, have had flu symptoms for greater than 48 hours or strep symptoms greater than 96 hours, or have an allergy to all antiviral therapies for influenza you are not eligible for testing at our pharmacies. Please schedule an appointment with your Primary Care Provider or local Urgent Care clinic for further testing.
I agree that I have read the above statement and have answered all questions truthfully and to the best of my knowledge
15. Please list any current medications (prescription, OTC, topical, pain or allergy, supplements, vitamins, etc.)
16. What medication allergies do you have, if any?
17. What treatments have you tried for your current concern, if any?
After signing and submitting this form, I will call the selected pharmacy below to schedule my appointment.
I agree to call Andover Drug at (316) 260-6030
I agree to call Damm Pharmacy at (316) 788-5533
I agree to call Graves Drug - Winfield at (620) 221-0080
I agree to call Graves Drug - Ark City at (620) 442-2300
How did you hear about this service?
Parent or Guardian Signature
Continue
Continue
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