Elewell Care Integrative
Patient Base Information Visit
By completing this assessment, I agree to share this information with my provider and agree to an e-visit if necessary.
1
Are you experiencing life-threatening symptoms or a medical emergency?
Yes
No
Unfortunately, we do NOT treat life-threatening conditions online. Please call 911
2
Are you currently taking any medications?
Yes
No
Add Current Medicaitons
3
Medical History:
Allergies
Chronic Conditions
Surgical History
Family Medical History
4
What is the reason for this visit?
Preventive Visit – General Visit
Health Screenings and Early Detection
Immunization/Vaccine Visits
Monitoring Overall Health
Dietary Habits
Weight Loss Plans
Identifying Risk Factors
Updating Health Records
Post-Hospitalization Follow-up
Post-Treatment Follow-up
Lab Test/Blood Work Follow-ups
Preventive Care & Counseling
Age-and Gender-Specific Concerns
Mental and Emotional Well-Being
Planning for the Future
Sexual and Reproductive Health
Vision and Hearing Check
Cold & Flu
COVID-19 concerns
Ear pain
Chills
Cough
Fatigue
Fever
Runny or stuffy nose
Sinus infection
Sore throat
Skin
Bug bites
Cuts
Acne
Athlete's foot
Diaper rash
Dry skin & eczema
Poison ivy/oak
Rashes & hives
Eye
Eye irritation
Pinkeye/conjunctivitis
Stye
Gastrointestinal
Constipation
Diarrhea
Heartburn/GERD
Nausea/upset stomach
Vomiting
Neurologic
Abnormal movements
Dizziness
Headaches
Weakness
Respiratory
Seasonal allergies
Bronchitis
Chest congestion
Body Aches & Pains (without fever)
Arm or leg pains
Back pain
General body aches
Joint pains
Genital or Urinary
Pain with urination
Sexually transmitted diseases (STDs)
Urinary tract/bladder infections
Yeast infection
Other
Help with appointment
Prescription issues
Work note/school note request
Add a note if none listed or message to the Group
5
When did you start experiencing these symptoms?
6
Do you have any additional questions or concerns?
Upload Document
Important Notification:
By completing and submitting any assessment you give consent for an e-visit and a co-pay may or may not apply.
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