Influenza/Strep Patient Information (Adult)
Today's Date
Name
Date of Birth
/
Month
/
Day
Year
Date
Age
Gender
Email
example@example.com
Address
Format: (000) 000-0000.
Address
Address
Street Address Line 2
City
State
Zip
Primary Care Provider
What test are you looking to receive today?
Influenza
Strep
Both influenza and strep
Primary Care Phone
Format: (000) 000-0000.
1. Are you 18 years of age or older?
Yes
No
2. Are you pregnant or breastfeeding?
Yes
No
3. Have you ever been diagnosed with a weakened immune system? (e.g., cancer, HIV/AIDS, transplant, long term steroids, etc.)
Yes
No
4. Do you have a history of rheumatic fever, rheumatic heart disease, scarlet fever?
Yes
No
5. Do you require supplemental oxygen?
Yes
No
6. Have you tested positive for an upper respiratory infection in the previous four weeks?
Yes
No
7. If you answered "Yes" to question 6, have you been tested somewhere else and are awaiting those results?
Yes
No
8. Have you had your tonsils removed within the last 30 days?
Yes
No
9. How long have your symptoms been present?
0-24 hours
24-48 hours
48-96 hours
Longer than 96 hours
If you have answered "Yes" to any questions 2-8, have had flu symptoms for greater than 48 hours, or strep symptoms greater than 96 hours, 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 treatment.
I agree I have read the above statement and have answered all questions truthfully and to the best of my knowledge
10. 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 statement, please explain:
11. 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
12. Please list any current medications (prescription, OTC, topical, pain or allergy, supplements, vitamins, etc.)
13. What medication allergies do you have, if any?
14. 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?
Signature
Continue
Continue
Should be Empty: