2026 Mission Patient Encounter Form
Brigada Médica Colombia | September 2026
SECTION 1 — ENCOUNTER IDENTIFICATION
Patient ID
*
Encounter Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Mission Location
*
Please Select
Main Brigada: Galerazamba
Pasacaballos
Other
New or Returning Patient
*
New Patient
Returning Patient
SECTION 2 — PATIENT DEMOGRAPHICS
First Name
*
Last Name
*
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
Sex
*
Female
Male
Other / Not specified
Parent/Guardian
Phone/WhatsApp
Please enter a valid phone number.
Format: (000) 000-0000.
City/Town
*
SECTION 3 — REGISTRATION / TRIAGE
Reason for Visit
General medical evaluation
Orthopedic/musculoskeletal
Pediatric concern
Pain
Neurologic/developmental
Skin condition
Respiratory
Gastrointestinal
Vision
Dental/oral
Medication need
Equipment/assistive device
Follow-up from previous mission
OB/GYN
Other
Other reason details
Allergies
No known allergies
Yes
Unknown
Allergy details
Current Medications
None
Yes
Unknown
Current medication details
Relevant Medical History
*
SECTION 4 — RELEVANT MEDICAL HISTORY
Significant Conditions
None known
Cerebral palsy
Developmental delay
Neurologic disorder
Seizure disorder
Asthma
Diabetes
Hypertension
Heart disease
Kidney disease
Sickle cell/hematologic disorder
Cancer
Prior orthopedic condition
Prior surgery
Other: ________
Previous Surgery
Yes
No
Unknown
Procedure / approximate year:
SECTION 5 — CLINICAL EVALUATION
Clinical Service
*
Please Select
Pediatrics
Orthopedics
Neurology
PM&R/Rehabilitation
Primary/General Medicine
OB/GYN
Optometry/Ophthalmology
Other
Other:
Clinician Name
Clinical Findings
SECTION 6 — DIAGNOSIS
Primary Diagnosis Category
*
Please Select
Normal/well-child evaluation
Musculoskeletal/orthopedic
Cerebral palsy
Neuromuscular condition
Developmental condition
Neurologic
Respiratory
Gastrointestinal
Dermatologic
Infectious
Cardiovascular
Genitourinary
Endocrine/metabolic
Nutritional
Pain
Injury/trauma
Other
Primary Diagnosis
Please Select
Normal/well-child evaluation
Musculoskeletal/orthopedic
Cerebral palsy
Neuromuscular condition
Developmental condition
Neurologic
Respiratory
Gastrointestinal
Dermatologic
Infectious
Cardiovascular
Genitourinary
Endocrine/metabolic
Nutritional
Pain
Injury/trauma
Other
Primary Diagnosis (if not listed)
Secondary Diagnosis(es)
Diagnosis Status
Please Select
Known/pre-existing
New diagnosis
Suspected / needs further evaluation
Unable to determine
SECTION 7 — CLINICAL PLAN
Plan — Select All That Apply
Reassurance/education
Observation
Medication
Physical therapy
Occupational therapy
Home exercise program
Orthotics/bracing
Assistive equipment
Imaging
Laboratory testing
Specialist referral
Surgical evaluation
Follow-up with local physician
Foundation follow-up
Emergency/urgent evaluation
No additional treatment needed
Other
Additional Plan Details
SECTION 8 — MEDICATIONS
Medication Given During Mission
*
Yes
No
Medication
Dose
Frequency
Duration
Quantity Dispensed
Prescription/Recommendation Only
Yes
No
Medication / Instructions
Section 9 — Equipment / Supplies
Equipment Provided Today?
None
Crutches
Walker
Wheelchair
Brace/orthosis
Splint
Sling
Wound supplies
Other
Equipment Needed But NOT Available?
Yes
No
Equipment needed
Section 10 — Imaging / Testing
Testing Recommended
None
X-ray
Ultrasound
MRI
CT
Laboratory testing
Other
Other test
Testing Completed During Mission?
Yes
No
Not applicable
Results / Important Findings
SECTION 11 — REFERRAL
Referral Required?
*
Yes
No
Referral to
Please Select
Pediatrics
Orthopedics
Neurology
Neurosurgery
PM&R/Rehabilitation
Physical therapy
Occupational therapy
Cardiology
General surgery
Oncology
Local hospital
Emergency department
Other
Urgency
Please Select
Urgent — immediate/within 24 hours
Priority — within 1–2 weeks
Routine — within 1–3 months
Non-urgent / when available
Referral Reason
Follow-up Required?
Yes
No
Follow-up Urgency or Timeframe
Within 24 hours
Within 1 week
Within 2 weeks
Within 1 month
As needed
Follow-up Owner or Responsible Team
Exception Notes
SECTION 12 — FOUNDATION FOLLOW-UP
Does This Patient Need Foundation Follow-Up?
YES
NO
Follow-Up Needed For
Clinical reassessment
Orthopedic evaluation
Surgery consideration
Imaging
Laboratory testing
Medication
Therapy
Brace/orthosis
Wheelchair/equipment
Specialist referral
Social support/resources
Other
Follow-Up Notes
SECTION 13 — CHECKOUT
Before Patient Leaves
Encounter Status
*
COMPLETE
INCOMPLETE — requires attention
SECTION 14 — INTERNAL MISSION DATA
Entered by
Clinical provider
Registration volunteer
Checkout volunteer
Mission year
Save
Submit
Should be Empty: