General Medicine Clinic: Dr C Osuji

Please complete. If you have an additional person coming in to assist you with the visit, please have them complete this questionnaire. Make sure to add temperature with all details included, please. If completing for an appointment, complete form 10 days or less before coming to office. If unable to complete the form, please call office.

Name * Date of Birth * Phone number *

Your Symptoms

SYSTEMIC OR DANGEROUS SYMPTOMS

Experiencing shortness of breath or trouble breathing (Dyspnea) Systemic or dangerous symptoms Able to complete daily actiivities Dyspnea severity Dyspnea exacerbating factors Abdominal pain severity Number of vomiting episodes in past 48 hours Vomiting is only post-tussive Able to keep fluids down Bowel movements in past day Last bowel movement

SYMPTOM COURSE

Length of present Illness (days) Current symptom severity compared to initial severity Has had cough during this illness Has felt fevers or chills Symptoms Chest pain severity Chest pain characteristics Still experiencing fevers or chills Uncontrollable shaking with chills Temperature taken with thermometer Type of thermometer used Highest temperature Thermometer nearby Type of thermometer Current temperature Initial temperature too low; 2nd try Change in cough since beginning Frequency of coughing Coughing up phlegm Phlegm characteristics Amount of hemoptysis Has gotten COVID-19 vaccine * Which COVID-19 vaccine Number of doses of the COVID-19 vaccine received When got first dose of the COVID-19 vaccine When got second dose of the COVID-19 vaccine Got flu vaccine this year

SOCIAL HISTORY

Recent contacts (prior 14 days) have tested positive for COVID-19 Description of recent COVID-19 contacts Recent sick contacts Description of recent sick contacts Smokes cigarettes or another form of tobacco Has traveled out of state in the past three weeks Type of travel in past three weeks Foreign Travel details

Medical History

TREATMENTS TRIED

Tried treatments for current symptoms Which treatments

MEDICAL HISTORY

Has immunosuppressive condition Medical conditions

FEMALE HISTORY

Pregnant or Planning Trimester When planning to get pregnant Breastfeeding

ANYTHING ELSE

Anything else patient would like to share