Back Pain Telemedicine Visit
  • Date of Birth*
     - -

  •
  • Format: (000) 000-0000.
  • What was your gender at birth?*

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

    • Severe or 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 back pain begin?*
  • Did your back pain begin suddenly?*
  • Where is your back pain located? (Select ALL that apply)*
  • Which side is the pain on?*
  • Please describe your back pain. (Select ALL that apply)*
  • Does pain decrease when bending forward?*
  • Please rate the severity of your back pain on a pain scale, with 0 being no pain and 10 being the worst pain imaginable.*
  • Does the back pain shoot to other areas?*
  • Which of the following areas does your back pain shoot to? (Select ALL that apply)*
  • Since the back pain began, have you noticed numbness or tingling in your legs?*
  • Since the back pain began, have you noticed weakness in your legs?*
  • Is there any numbness in your inner thighs, groin, or buttocks?*
  • Since the back pain began, have you noticed any of the following? (Select ALL that apply)*
  • Since the back pain began, have you experienced loss of bladder control?
  • Since the back pain began, have you experienced loss of bowel control?*
  • Since the back pain began, have you been unable to empty the bladder?*
  • When barefoot, are you able to walk on toes with heels off the ground?*
  • When barefoot, are you able to walk on heels with toes off the ground?*
  • Do you feel feverish?*
  • Are you able to take your temperature or have you taken your temperature within the last 12 hours?*
  • In the last 3 months, have you had unintended weight loss of more than 10 lbs that is not due to increased exercise or dieting?*
  • Did your back pain begin after any of the following? (Select ALL that apply)*
  • Have you had similar back pain in the past?*
  • Did you already see a provider to treat this instance of back pain?
  • What did the provider recommend for the back pain?*
  • What other treatment approaches were recommended to manage this episode of back pain? (Select ALL that apply)*
  • Have you used any of the following to manage this episode of back pain? (Select ALL that apply)*
  • What other treatment approaches have you tried to manage this episode of back pain? (Select ALL that apply)*

  • MEDICAL HISTORY

  • Have you ever had any of the following?*
  • Have you been told by a provider to avoid NSAIDs?
  • Do you have any medication allergies?*
  • Are you currently taking any medications?*
  • Are you pregnant?*
  • Are you breastfeeding?*

  • PHARMACY INFORMATION

    Please choose where you would like your prescription sent
  • Would you like to add any additional information or questions for the provider to see?*

  • My Products*

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