CARY ADULT MEDICINE

Please complete this form for an e-visit for any respiratory complaints

Name * Date of Birth * Have you completed an E-Visit in past 6 months? What type of Insurance do you have? Please List any medication allergies * When was your last office visit (approx)? How Long have you had the symptoms * Have you had any contact with patient that has been diagnosed with Coronavirus or Flu? * Have you had fever of over 100 degrees in past 5 days

If you had fever please tell us last time you had fever over 100 degree, did it come down after taking Tylenol, ibuprophen, advil or alleve, and how frequent is the fever

If yes to fever please answer above questions about fever Have you Tried Over the Counter Meds If Yes to above Which ones? Do you have any change in color of your mucous? Are you coughing? Do you have any Chest Pain? Are you short of breath? Are your symptoms getting worse? If you have had any changes in your medical history or any new allergies please list Do your Ears Hurt ? Can you breath through your nose? Is your throat sore? Is it difficult to swallow? When does your throat hurt? Please list any other comments about your current medical issues including medication allergies not listed Preferred Contact Preferred Contact Number or Email