Point of Care Testing Intake Form

  • Point of Care Testing Patient Intake Form

  • Date of Birth
     - -

  • Contact Information

  • Format: (000) 000-0000.
  • Do you have a primary care physician?

  • Health Information

  • Do you have any allergies?
  • Are you currently taking any prescription or over-the-counter (OTC) medications?
  • Do you have any health conditions or medical history we should be aware of?
  • Which of the following test(s) are you planning to receive?*

  • Infectious Disease Testing Questionnaire

  • Check any of the following symptoms you are currently experiencing:
  • Approximately when did your symptoms start?
     - -
  • Have you taken any medications for these symptoms?
  • Are you a current smoker?
  • Any other recent medical concerns?

  • COVID-19 Testing Questionnaire

  • Any recent exposure to someone with COVID?
  • Any recent travel (past 14 days)?
  • Have you received a COVID vaccine?
  • Date of last dose:
     - -
  • Any prior COVID infection?

  • Influenza Testing Questionnaire

  • Any recent exposure to someone with the flu?
  • Did you get a flu shot this season?

  • Strep Throat Testing Questionnaire

  • Any recent exposure to someone with strep?

  • Lyme Disease Testing Questionnaire

  • Any recent activity in wooded/grassy areas?
  • Any known tick bites?
  • Any rash present (especially bullseye pattern)?
  • Any prior diagnosis of Lyme disease?

  • Nutrition & Wellness Testing Questionnaire

  • Check any of the following symptoms you are currently experiencing:
  • Have you had this test done before?

  • Vitamin D Testing Questionnaire

  • Do you have a history of bone fractures or osteoporosis?
  • Do you take any vitamin D supplements?

  • Vitamin B12 Testing Questionnaire

  • Do you follow a vegetarian or vegan diet?
  • Do you take vitamin B12 supplements or injections?

  • Omega-3 Testing Questionnaire

  • Do you regularly eat fatty fish (salmon, sardines, etc.)?
  • Do you take any fish oil or omega-3 supplements?

  • Prenatal DHA Testing Questionnaire

  • Are you currently pregnant?
  • Are you taking a prenatal vitamin or DHA supplement?
  • Have you discussed nutritional needs with your OB/GYN?

  • Adrenal Stress Testing Questionnaire

  • Have you had any recent major life stressors?

  • Chronic Disease Testing Questionnaire

  • 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 your A1C tested before?
  • Have you had your cholesterol tested before?
  • Have you had an InBody scan before?
  • Do you smoke or use tobacco products?
  • Do you consume alcohol?
  • Do you engage in regular physical activity?

  • Cholesterol Testing Questionnaire

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

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

  • Blood Pressure Testing Information

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

  • InBody Testing Questionnaire

  • How would you describe your overall eating habits?
  • Are you currently following a nutrition, weight loss, or fitness plan?

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

  • INR Testing Questionnaire

  • Check any of the following symptoms you have been experiencing:
  • Are you currently taking warfarin (Coumadin, Jantoven)?
  • Do you ever miss doses or take extra doses?
  • Have you had INR testing done before?
  • Have you started, stopped, or changed any medications recently?
  • Do you consistently eat foods high in vitamin K (leafy greens, broccoli, etc.)?
  • Any recent dietary changes (new diet plan, fasting, etc.)?
  • Have you had any recent illnesses or infections?
  • Have you had any recent surgeries, falls, or injuries?
  • Do you consume alcohol?

  • TB Skin Testing Questionnaire

  • Have you had a TB skin test done before?
  • Have you ever had contact with someone with known TB?
  • Have you ever received the BCG vaccine for TB?
  • Have you ever received preventative treatment?
  • Check any of the following that apply:
  • I understand that I must return within 48-72 hours after the TB skin test is administered to have it read.

  • Cognivue Testing Questionnaire

  • 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?
  • Have you had a neurological evaluation (MRI, CT, etc.)?
  • Do you smoke or use tobacco products?
  • Do you consume alcohol?
  • Do you consume caffeine?
  • Do you engage in regular physical activity?

  • Patient Consent and Acknowledgement

  • 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.

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