Telehealth Visit Patient Triage and Reason for Visit Questionnaire

Telehealth Visit Patient Triage and Reason for Visit Questionnaire
Name

First NameMiddle NameLast NameSuffix
Reason for Visit
What is your main concern today? (Choose one or more)

Urinary symptoms (e.g., burning, frequent urination)Viral illness symptoms (e.g., fever, body aches)Sinus symptoms (e.g., congestion, facial pain)Eye symptoms (e.g., redness, discharge)Other
Other (please specify):
When did your symptoms start? (Provide an approximate date or timeframe)
Have you experienced these symptoms before?

Yes, frequentlyYes, occasionallyNo, this is the first time
Symptom Details

(Based on the reason selected above)
For Urinary Symptoms
Do you have

Pain or burning during urinationIncreased urgency or frequency of urinationLower abdominal or back painCloudy or foul-smelling urineBlood in your urine
Do you have a history of urinary tract infections (UTIs)?

YesNo
Are you currently pregnant? (If applicable)

YesNo
For Viral Illness Symptoms
Are you experiencing

Fever or chillsBody aches or fatigueSore throatCoughRunny or stuffy nose
Do you have any other flu-like symptoms? (Specify if needed)
For Sinus Symptoms
Do you have

Nasal congestion or stuffinessPain or pressure in your face or headPostnasal dripDiscolored nasal discharge (yellow/green)Fever
Have you been diagnosed with sinus infections before?

YesNo
For Eye Symptoms
Are you experiencing

Redness in one or both eyesDischarge or crusting? (If yes, describe the color and consistency)Itching or burning in the eyesSensitivity to lightBlurry vision
For other concerns please explain symptoms
Medical History
Do you have any allergies? (Include medication, food, or environmental allergies)
List all current medications, including over-the-counter and supplements:
Do you have any chronic medical conditions? (e.g., diabetes, hypertension, asthma)
Have you recently started any new medications or supplements?
Have you had any recent surgeries or hospitalizations?
Additional Questions
Have you recently been exposed to anyone with similar symptoms?

YesNo
Do you have any additional symptoms or concerns you'd like to share?
Consent and Acknowledgment

I acknowledge that I am requesting a telehealth consultation and understand that this service is not for emergencies.

I confirm that the information provided is accurate and complete to the best of my knowledge.

I understand that JaeNix Med Spa does not accept or file insurance, including prior authorizations. Referrals for additional care can be provided if needed.

I confirm that I am not experiencing any emergency symptoms. I understand that if I am experiencing a medical emergency, I should call 911 or go to the nearest emergency room.
Signature
Date

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Date
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Telehealth Visit Patient Triage and Reason for Visit Questionnaire

Reason for Visit

Symptom Details

For Urinary Symptoms

For Viral Illness Symptoms

For Sinus Symptoms

For Eye Symptoms

Medical History

Additional Questions