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

Choose your medical practice 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 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 fever? 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