Point of Care Testing Intake Form

Which of the following test(s) are you planning to receive?*

Check any of the following symptoms you are currently experiencing:

Approximately when did your symptoms start?

Date

Have you taken any medications for these symptoms?

YesNo

What have you taken and when?

Are you a current smoker?

YesNo

Any other recent medical concerns?

YesNo

Please explain:

Any recent exposure to someone with COVID?

YesNo

Who/when?

Any recent travel (past 14 days)?

YesNo

Where?

Have you received a COVID vaccine?

YesNo

Date of last dose:

Date

Any prior COVID infection?

YesNo

When?

Any recent exposure to someone with the flu?

YesNo

Who/when?

Did you get a flu shot this season?

YesNo

Any recent exposure to someone with strep?

YesNo

Who/when?

Any recent activity in wooded/grassy areas?

YesNo

Please briefly describe:

Any known tick bites?

YesNo

When?

Any rash present (especially bullseye pattern)?

YesNo

How long have you had it?

Any prior diagnosis of Lyme disease?

YesNo

When?

Check any of the following symptoms you are currently experiencing:

Why are you seeking this test?

Have you had this test done before?

YesNo

When?

Results?

Do you have a history of bone fractures or osteoporosis?

YesNo

Do you take any vitamin D supplements?

YesNo

Dosage:

How much time do you spend outdoors weekly?

Do you follow a vegetarian or vegan diet?

YesNo

Do you take vitamin B12 supplements or injections?

YesNo

Dosage:

Do you regularly eat fatty fish (salmon, sardines, etc.)?

YesNo

Do you take any fish oil or omega-3 supplements?

YesNo

Dosage:

Are you currently pregnant?

YesNo

Trimester:

Are you taking a prenatal vitamin or DHA supplement?

YesNo

Brand/dosage:

Have you discussed nutritional needs with your OB/GYN?

YesNo

Have you had any recent major life stressors?

YesNo

Please describe:

Check any of the following symptoms or concerns you are currently experiencing:

What is your main health goal or concern right now (weight loss, diabetes risk, monitoring progress, etc.)?

Have you ever been diagnosed with any of the following?

Have you had your A1C tested before?

YesNo

When?

Results (if known):

Have you had your cholesterol tested before?

YesNo

When?

Results (if known):

Have you had an InBody scan before?

YesNo

When?

Results (if known):

If you monitor any of the following at home, please describe your usual readings:

Do you smoke or use tobacco products?

YesNo

Do you consume alcohol?

YesNo

How often?

Do you engage in regular physical activity?

YesNo

What type(s) and how often?

Do you follow a specific diet for cholesterol or heart health?

YesNo

Note: Please do not eat or drink anything (besides water) for 8-12 hours before your cholesterol test.

Please avoid caffeine and nictoine for at least 30 minutes before your blood pressure test.

How would you describe your overall eating habits?

ExcellentAverageNeeds improvement

Are you currently following a nutrition, weight loss, or fitness plan?

YesNo

Please briefly describe:

Note: Please avoid drinking alcohol for 24 hours before your InBody scan and eating or exercising for 3 hours before your scan.

Check any of the following symptoms you have been experiencing:

Are you currently taking warfarin (Coumadin, Jantoven)?

YesNo

What dose are you currently taking?

What time of day do you usually take it?

Do you ever miss doses or take extra doses?

YesNo

Please explain:

When was your last dose taken?

Have you had INR testing done before?

YesNo

When was your last test?

Results (if known):

What is your target INR range (if known)?

Have you started, stopped, or changed any medications recently?

YesNo

Please list changes:

Do you consistently eat foods high in vitamin K (leafy greens, broccoli, etc.)?

YesNo

Any recent dietary changes (new diet plan, fasting, etc.)?

YesNo

Please briefly explain:

Have you had any recent illnesses or infections?

YesNo

Have you had any recent surgeries, falls, or injuries?

YesNo

Do you consume alcohol?

YesNo

How often?

Have you had a TB skin test done before?

YesNo

When?

Where?

Reaction:

Reason for skin test:

Have you ever had contact with someone with known TB?

YesNo

When?

Who?

Have you ever received the BCG vaccine for TB?

YesNo

When?

Have you ever received preventative treatment?

YesNo

Check any of the following that apply:

Why are you seeking this test?

I understand that I must return within 48-72 hours after the TB skin test is administered to have it read.

YesNo

Check any of the following symptoms or concerns you are currently experiencing:

Have you ever been diagnosed with any of the following?

Have you had a cognitive screening before?

YesNo

When?

Results (if known):

Have you had a neurological evaluation (MRI, CT, etc.)?

YesNo

Please explain:

Do you smoke or use tobacco products?

YesNo

Do you consume alcohol?

YesNo

How often?

Do you consume caffeine?

YesNo

How often?

Do you engage in regular physical activity?

YesNo

What type(s) and how often?

How would you describe your sleep?

Average hours per night:

I understand that I have the right to information regarding my medical care, testing, and treatment, including information for informed consent. I have been given the opportunity to ask questions before I continue and I have been told that I can ask other questions at any time. By continued use of this application interface to facilitate my testing and/or treatment, I authorize any treatment, sample collection, testing, and disclosure of any results to my healthcare provider and any Health Information Exchanges in which they participate, test administrator, county, state, or to any other governmental entity as may be required by law. I authorize communication of any test results or other follow up to me by email, voice mail, or text message, in accordance with the contact information I provided. I accept any risk of disclosure of medical information or test results to the contact information I provided, including by third parties accessing my devices. I understand that this application interface is facilitating provision of my care, but not acting as my medical provider. I assume complete and full responsibility to take appropriate action with regards to any test results or recommended treatment. I agree that I will seek medical advice, care, and treatment from my medical provider if I have questions or concerns, or if my condition should worsen. I understand that, with respect to any medical testing, there is potential for false positive or false negative test results. I also understand that my information will be submitted for reimbursement claims, treatment purposes, and other healthcare operations in accordance with the Notice of Privacy Practices of my provider. I release and waive any claim against Jotform, its affiliates, successors, and assigns, that may arise from testing or medical care facilitated through this application interface. By continuing, I represent that I am either the patient or authorized to act on behalf of the patient.

By signing below, I certify that I am the patient or the patient's parent/legal guardian signing on behalf of the patient, and that I have read, understand, and agree to all statements on this form.*

Name of person granting consent:

First NameLast Name

Relationship to minor:

Point of Care Testing Patient Intake Form

Contact Information

Health Information

Infectious Disease Testing Questionnaire

COVID-19 Testing Questionnaire

Influenza Testing Questionnaire

Strep Throat Testing Questionnaire

Lyme Disease Testing Questionnaire

Nutrition & Wellness Testing Questionnaire

Vitamin D Testing Questionnaire

Vitamin B12 Testing Questionnaire

Omega-3 Testing Questionnaire

Prenatal DHA Testing Questionnaire

Adrenal Stress Testing Questionnaire

Chronic Disease Testing Questionnaire

Cholesterol Testing Questionnaire

Blood Pressure Testing Information

InBody Testing Questionnaire

INR Testing Questionnaire

TB Skin Testing Questionnaire

Cognivue Testing Questionnaire

Patient Consent and Acknowledgement