Upper Respiratory

Name*

First NameLast Name
Date of Birth*

MonthDayYear
Age*
Phone Number*
Please enter a valid phone number.
What is your birth-assigned gender?*

FemaleMale
Height (inches)*
Weight (lbs)*
Email*

Confirmation Emailexample@example.com
Legal Guardian's Name*

First NameLast Name
I attest that I am the legal guardian and consent to treatment of the minor listed above. *

Clear

Terms of Service
I am not covered by Medicare or MedicaidI am covered by Medicare or Medicaid and I agree to the terms of the Advanced Beneficiary Notice (ABN)
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*

Yes, I am having an emergencyNo, I am not having an emergency

When did your symptoms start?*

Today1-2 days ago3-5 days ago6 days ago7-9 days ago10-13 days ago2-3 weeks ago1 month or more agoI do NOT have any symptoms

Which ear hurts?*

RightLeftBoth
Where is your ear pain located?*

Outside (external surface) the ear(s)Inside the ear(s)Both outside (external surface) and inside the ear(s)

Please rate the severity of your ear pain on a pain scale, with 0 being no pain and 10 being the worse pain imaginable.*

1-3 = Mild pain4-6 = Moderate pain7-9 = Severe pain10 = Unbearable
Does the pain get worse when your earlobe is gently pulled?*

YesNo

Please indicate where your ear(s) is tender to the touch. (Select ALL locations that apply).*

(A) Ear canal (passage from the outer ear to inner ear)(B) Tragus (small pointed flap of the ear)(C) Helix (outer rim of the ear)(D) Ear lobe (soft lower part of the ear)(E) Mastoid process (bone behind the ear at the base of the skull)

Do you have fluid coming out of the ear(s)?*

YesNo
What color is the fluid coming out of your ear(s)? (Select ALL that apply).*

ClearWhiteYellowGreenBloody
Does the fluid have a bad odor?*

YesNo

Have you participated in any of these activities in the past week?*

SwimmingFlyingNONE of the above
Is it possible an object could be inside your ear?*

YesNo
Have you experienced any recent injuries in the area around the ear?*

YesNo

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).*

ClearWhiteYellowGreenBlood-tingedBloodyBrown

Rate the severity of your throat pain on a pain scale, with 0 being no pain and 10 being the worse pain imaginable.*

1-3 = Mild pain4-6 = Moderate pain7-9 = Severe pain10 = Unbearable

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?*

Yes, I can swallow liquids without any difficultyYes, I can swallow liquids with mild discomfortYes, I can swallow liquids but it is very painfulNo, I cannot swallow any liquids at all

Please feel your neck. Are the lymph nodes in the neck enlarged?*

YesNoNot sure
Is the lymph node swelling worse on one side?*

YesNo
Has the swelling caused any changes in your speech or hoarseness in your voice?*

YesNo

Are you experiencing difficulty opening the mouth due to pain or swelling in the jaw muscles?*

YesNo
Are you feeling pain in the front of the neck muscle that sometimes moves to the ear?*

YesNo
Has a rash appeared on your skin since the sore throat started?*

YesNo

Within the past week, have you been near anyone with any of the following?*

Strep throatInfluenza (Flu)CovidNot Sure

Have you been told by a provider to avoid NSAIDs?*

YesNo
Have you used any over-the-counter treatments or home remedies for the current symptoms?

YesNo
Please list the treatments/remedies you have used for the current symptoms:*

Medication Allergies
Do you have any allergies to prescription or over-the-counter medications?*

YesNo known drug allergies (NKDA)
List your medication allergies below:*

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?*

YesNo
Please enter the additional information below:

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.
Pharmacy Name: *
Pharmacy Address*

My Products*

Acute Telemedicine Visit

$39.00

Enter coupon

Total

$0.00

Terms of Service