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Telemedicine Consent
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Presenting Problem
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History of Present Illness
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ALLERGIES
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Allergies
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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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MEDICATION LIST
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Current Medications List
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MEDICAL HISTORY
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Past Medical History
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Past Surgical History
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Family History
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Social History
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REVIEW OF SYSTEMS
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ROS
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PHYSICAL EXAMINATION
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Physical Examination
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LABS
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Labs
• • •
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Lab Data
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Lab Comments
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RADIOLOGY
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Radiology
• • •
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Radiology Comments
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ASSESSMENT & PLAN
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Assessment & Plan
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Education and Counseling
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Education and Counseling
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Smoking Cessation Counseling
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Return To Clinic
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RTC
• • •
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Follow-Up Plan Comments
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Dr. Singh Signature
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Time Spent
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