Minor Urgent Care Form
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Date of Visit
*
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
What brings you in today?
*
When did your symptoms start?
*
Have you tried anything for it at home? If yes, please explain.
Are you also experiencing any of the following? Please select.
Fever
Chills
Dizziness
Shortness of breath
Nausea
Rash
Swelling
Chest Pain
Difficulty swallowing
Neck stiffness
Persistent vomiting
Past Medical History
Rows
Yes
No
Hypertension
Heart disease
Diabetes
COPD
Asthma
Hypothyroidism
Kidney Disease
Clinical Notes:
Any other medical history you would like us to know about:
Do you have any allergies?
Yes
No
If yes, please list.
What medications do you take?
Client Signature
*
Provider Signature
*
Date
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: