Upper Respiratory
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • What is your birth-assigned gender?*

  • Terms of Service

  • *

  • Advance Beneficiary Notice

    Patient is solely responsible for paying out-of-pocket the full charge for this visit. This service is not covered under Medicare or Medicaid. Omnia TeleHEALTH will not submit a bill to or request for payment from Medicare and Medicaid or any other payor.

  • You should not use Omnia TeleHEALTH if you are experiencing an emergency. Emergencies include but are not limited to:

    • Severe of unusual chest pain
    • Severe shortness of breath
    • Symptoms of a stroke (such as facial drooping, arm weakness, or speech difficulties)
    • Thoughts of harming yourself or others
  • Are you experiencing an emergency? If you are experiencing an emergency, call 911 or go to an emergency room immediately*
  • When did your symptoms start?*
  • How quickly did your symptoms start?*
  • After your symptoms started, did they improve and then get worse again?*
  • What symptoms are you experiencing? (Select ALL that apply).*
  • Which ear hurts?*
  • Where is your ear pain located?*
  • Please rate the severity of your ear pain on a pain scale, with 0 being no pain and 10 being the worse pain imaginable.*
  • Does the pain get worse when your earlobe is gently pulled?*
  • Is the ear pain worse when eating or chewing?*
  • In addition to the ear pain, are you experiencing any of the following symptoms?*
  • What is the color of the affected area? (Select ALL that apply).*

  • Please indicate where your ear(s) is tender to the touch. (Select ALL locations that apply).*
  • Do you have fluid coming out of the ear(s)?*
  • What color is the fluid coming out of your ear(s)? (Select ALL that apply).*
  • Does the fluid have a bad odor?*
  • Have you participated in any of these activities in the past week?*
  • Is it possible an object could be inside your ear?*
  • Have you experienced any recent injuries in the area around the ear?*
  • Have you ever had tubes placed in the ear(s) to drain fluid?*
  • Are your tubes still in place?*

  • Color helps provide description to the provider, but it does NOT help decide if the condition is viral or bacterial or if antibiotics will be prescribed. 

  • What color is your mucus? (Select ALL that apply).*
  • How often do you cough?*
  • Is the cough more bothersome at night?*
  • Does anything (phlegm) come up into the throat when you cough?*
  • Do you think the cough is caused by post-nasal drip (the phlegm going down the back of the throat)?*
  • What is the color of your phlegm? (Select ALL that apply).*
  • Rate the severity of your throat pain on a pain scale, with 0 being no pain and 10 being the worse pain imaginable.*

  • Being unable to swallow any liquids, including one's own saliva, may indicate a very serious condition called epiglottitis. Please be seen in the emergency room if liquids cannot be swallowed. 

  • Can you swallow liquids?*

  • Please feel your neck. Are the lymph nodes in the neck enlarged?*
  • Is the lymph node swelling worse on one side?*
  • Has the swelling caused any changes in your speech or hoarseness in your voice?*

  • Do you have white spots on the back of the throat?*
  • Are you experiencing difficulty opening the mouth due to pain or swelling in the jaw muscles?*
  • Are you feeling pain in the front of the neck muscle that sometimes moves to the ear?*
  • Has a rash appeared on your skin since the sore throat started?*
  • Within the past week, have you been near anyone with any of the following?*
  • Do you feel feverish?*
  • Is it possible to take your temperature now, or have you taken it within the last 12 hours?*
  • Do you currently have difficulty breathing?*

  • A pulse oximeter is a device that slides over the fingertip to measure the level of oxygen in blood. 

  • Do you have an oximeter available to check your oxygen level right now?*
  • Are you wheezing? Wheezing is a high-pitched sound that comes from the chest while breathing. It is commonly described as a whistling sound, similar to wind blowing through a tunnel.*
  • Do you currently have any of these symptoms? (Select ALL that apply).*
  • Does the facial pain or pressure feel worse when bending over or leaning forward?*
  • Please rate the severity of your headache on a pain scale, with 0 being no pain and 10 being the worse pain imaginable.*
  • Is your tooth pain from a cavity, recent dental work, or other mouth problems?*
  • Have you taken an antibiotic for similar symptoms in the past month?*
  • Since your symptoms started, have you been tested for COVID?*
  • What was the result of the COVID test?*
  • Since your symptoms started, have you been tested for influenza (flu)?*
  • What was the result of the influenza (flu) test?*
  • Have you been told by a provider to avoid NSAIDs?*
  • Have you used any over-the-counter treatments or home remedies for the current symptoms?
  • Have you been diagnosed with advanced kidney disease?*
  • Do any of the following immunosuppressive treatments or conditions apply to you? (Select ALL that apply).*
  • Do you have diabetes?*
  • Which of the following statements accurately reflects your diabetes?*
  • Do you have asthma?*
  • Do you have any of the following medical conditions? (Select ALL that apply).*
  • In the past 60 days, have you had sinus surgery?*
  • Within the past year, have you had a sinus infection*
  • How many sinus infections have you had within the past year?*
  • Depending on your symptoms, an antibiotic may be prescribed, which can sometimes cause yeast infections. Do you typically get a yeast infection when taking antibiotics?
  • What has successfully treated your yeast infections in the past? (Select ALL that apply).*
  • Do you typically need 1 or 2 doses of fluconazole (Diflucan) to resolve the yeast infection?*

  • Current Medications

  • Are you currently taking any medications?*

  • Medication Allergies

  • Do you have any allergies to prescription or over-the-counter medications?*
  • Are you pregnant?*
  • Are you breastfeeding?*

  • Before ending the interview, is there any additional information you would like to share about the following?

    • Symptoms
    • Recent changes in health
    • Medications or any other related health conditions
    • Any other relevant information about this visit
  • Would you like to share additional information?*

  • PHARMACY INFORMATION

    Please enter the pharmacy name and address where you would like your prescription sent. You should be able to enter the pharmacy name and city (in the Address section) to find the complete address.

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