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Telemedicine Consent
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CDCR #
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Referring Physician
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Presenting Problem
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Presenting Problem
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History of Present Illness
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History of Present Illness
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Past Medical History
• • •
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Past Medical History Comments
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Past Surgeries
• • •
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Past Surgeries Comments
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Allergies/Sensitivity to Meds or Food
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Allergies/Sensitivity to Meds or Food Comments
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Immunizations
• • •
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Other Immunizations
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Medications (names and doses)
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Blood Pressure(pt reported)
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SOCIAL HISTORY
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Smoking History
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Smoking History Comments
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Alcohol used weekly
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Alcohol Use Comments
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Drug Use
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Drug Use Comments
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Marital Status
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Number of Children
• • •
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Number of Children Comments
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Type of Work
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Disability Status
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Living Situation
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Living Situation Comments
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Driving
• • •
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Driver License Status
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Family History
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Family History
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Family History Comments
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Review of Systems
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General
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Other
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General Patient Denies
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Eyes ROS
• • •
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Other Eyes ROS
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No Eye Issues
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Ears, Nose, Mouth, and Throat ROS
• • •
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Other Ears, Nose, Mouth, and Throat ROS
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No Ears, Nose, Mouth, and Throat Issues
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Cardiovascular ROS
• • •
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Other Cardiovascular ROS
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No Cardiovascular Issues
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Pulmonary ROS
• • •
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Other Pulmonary ROS
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No Pulmonary Issues
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Musculoskeletal ROS
• • •
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Other Musculoskeletal ROS
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No Musculoskeletal Issues
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Gastrointestinal ROS
• • •
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Other Gastrointestinal ROS
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No Gastrointestinal Issues
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Urinary ROS
• • •
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Urinary ROS
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No Urinary Issues
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Endocrine ROS
• • •
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Other Endocrine ROS
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No Endocrine Issues
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Neurological ROS
• • •
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Other Neurological ROS
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No Neurological Issues
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Skin ROS
• • •
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Other Skin Issues
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No Skin Issues
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Psychiatric ROS
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Other Psychiatric ROS
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No Psychiatric Issues
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PHYSICAL EXAMINATION
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General
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Review of Records
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LABORATORY
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Lab Data
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RADIOLOGY
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Radiology
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NEUROPHYSIOLOGY
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Neurophysiology
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ASSESSMENT & PLAN
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Assessment & Plan
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Education and Counseling
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RTC
• • •
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Follow-Up Plan Comments
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Smoking Cessation Counseling
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Time Spent
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Dr. Usmanova's Signature
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