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TODAY'S PROVIDER
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PATIENT CONSENT - TELEMEDICINE ONLY
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Patient Consent
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Patient consent given for telemedicine by:
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Vitals Obtained
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Start Time
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End Time
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VITALS (Auto-filled)
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BMI Assessment (UNDER 18 YRS OLD)
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Height and Weight Obtained:
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For patients up to 30 months - Baby's Weight (lbs/oz):
/
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Is patient UNDER 24 MONTHS? If yes- no BMI assessment needed. GO TO NEXT SECTION.
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BMI Percentile (Under 18-refer to growth chart)
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BMI Assessment (Under 18 yrs)
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BMI for OVER 18 YRS OLD
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BMI Result
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Co-Morbidities
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BMI Value 40+ or without Co-Morbidities
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BMI Value 35+ for Morbid Obesity with Co-Morbidities
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BMI Value (auto-filled)
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BMI Assessed and Documented
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Choose Assessment and Plan (if obese, TURN ON button below)):
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TURN ON if pt. is obese (97802 with Z71.3 code drops with counseling verbiage)
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MEDICATION REVIEW & IMMUNIZATION STATUS
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Does child take medications prescribed by a doctor?
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List medications:
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Does child take over-the-counter medications / vitamins / supplements?
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List medications / vitamins / supplements:
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Does child have any allergies to medications?
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List medications:
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Are immunizations up to date?
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MEDICAL & SURGICAL HISTORY
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Does child have or has had any medical problems?
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List medical problems:
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Has child had any surgeries?
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List Surgeries (e.g. tonsils, appendix...)
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REVIEW OF SYSTEMS
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CONST
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Notes
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EYES
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Notes
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ENMT
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Notes
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CV
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Notes
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RESP
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Notes
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GI
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Notes
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GU
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Notes
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MUSC
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Notes
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SKIN
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Notes
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PSYCH
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Notes
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NEURO
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Notes
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Other ROS Notes
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EXAM / HEALTH ASSESSMENT
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ENMT
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Abnormal
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RESP
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Abnormal
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CARDIO
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Abnormal
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MUSC
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Abnormal
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SKIN
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Abnormal
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PSYCH
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Abnormal
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SEXUAL DEVELOPMENT / PUBERTY (for ages 9 - 15)
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TURN OFF if under 9 yrs old
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Axillary hair growth (self reported):
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Pubic hair growth (self-reported):
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TURN ON if Male patient: Taught and discussed self-testicular exam
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Genital Growth (self reported - scrotum, testicle, penis):
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TURN ON if Female patient: Taught and discussed self-breast exam
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Breast Development
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Has child started her period?
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If yes, at what age did it start?
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Is your menses regular or irregular?
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Is your menses normal or heavy?
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Is your menses painful, non-painful, or other?
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If other, please describe:
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ADDITIONAL ASSESSMENTS & PLANS
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Well Child Normal or Abnormal Status
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1. Assessment & Plan
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2. Assessment & Plan
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3. Assessment & Plan
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4. Assessment & Plan
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5. Assessment & Plan
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REFERRALS / NOTES TO PCP
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TURN ON for Referrals & NOTES TO PCP
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Referral to:
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Notes to PCP:
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