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Covid-19 / Respiratory Illness Screening
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Heart Rate
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Oxygen Saturation
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Have You Been Sick w/in Last 4 Weeks?
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Pre-existing Conditions Yes / No
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History/Subjective:
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Elective Care
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Appointment Notes (Dictate)
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Response To Previous Visit
• • •
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How They Feeling Today?
• • •
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Primary Complaint: Location
• • •
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Nature of Pain
• • •
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Pain Scale: Primary Complaint
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Timing
• • •
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Palliative
• • •
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Provocative
• • •
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Denies Numbness/Tingling
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tingling/numbness
• • •
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Secondary Complaint: Location
• • •
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Nature of Pain
• • •
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Tertiary Complaint: Location
• • •
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Nature of Pain
• • •
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Follow Up Appt Comments
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NEW INJURY?
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NEW INJURY? (Dictate)
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