URI questionaire

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URI questionnaire

Thank you for visiting us today and we’re sorry to hear about your symptoms. In this intake form, we will ask about your current symptoms and your medical history to guide safe, effective treatment of your symptoms. For any signs of a complicated infection, or if you’ve had antibiotic-resistant infections before, an in-person evaluation is recommended to ensure timely, appropriate care.

Yes, I’m ready to move forward

I would like to stop this encounter and see an in-person provider

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Your visit has been canceled

You chose not to proceed with this evaluation. No further action is required.

If you change your mind or need care later, you’re welcome to start a new visit at any time.

Find another visit type

Reproductive Health Screening

We ask these questions to ensure that any medication prescribed is safe based on your biological sex and pregnancy status.

What was your sex assigned at birth?

Male

Female

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Reproductive Health Screening

Are you currently pregnant or breastfeeding?

Yes

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Reproductive Health Screening

I understand that the medication prescribed to me by my healthcare provider may not be safe to take during pregnancy or when breastfeeding. I acknowledge that taking this medication while pregnant could pose risks to my health and the health of a developing fetus. By selecting below, I confirm that I have read and understand the information provided above. I consent to proceed with the treatment under these conditions.

I have read and understand the consent and wish to proceed

I do NOT wish to proceed

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Your measurements

What is your height?

What is your weight in pounds

Continue

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Validate

Submit

Your Symptoms

Is your cough dry (nonproductive) or productive (with sputum)?

Dry, nonproductive

Productive, sputum

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Your Symptoms

What is the sputum color and volume?

Clear/white; small volume

Clear/white; moderate volume

Clear/white; large volume

Yellow/green; small volume

Yellow/green; moderate volume

Yellow/green; large volume

Blood-tinged; small volume

Blood-tinged; moderate volume

Blood-tinged; large volume

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Your Symptoms

Are your symptoms worsening, stable, or improving?

Worsening

Stable

Improving

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Your Symptoms

Do any of the following make your symptoms worse?

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Your Symptoms

Do you have fever or chills?

Yes

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Your Symptoms

Have you recently been around anyone with an upper respiratory infection or similar symptoms as yourself?

Yes

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Your Symptoms

Have you traveled, been hospitalized, or taken antibiotics in the past 90 days?

Yes

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Past Treatment

Have you tried to treat your symptoms yet?

Yes

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Your Symptoms

Which treatments have you tried for your cough? (Select all that apply)

Antibiotics

Inhaled bronchodilators or steroids

Antitussives (e.g., dextromethorphan)

Acid-suppressive therapy (e.g., PPIs)

None

Continue

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Submit

Past Treatment

Have you experienced any complications or adverse reactions to those treatments?

Yes

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Medical History

Have you ever been diagnosed with any of the following? (Select all that apply)

Pneumonia

Asthma

COPD

Heart failure

GERD (Gastoesophageal Reflux Disease)

None of the above apply to me

Continue

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Submit

Medical History

What is your tobacco/vaping history?

Current user

Former user

Never used

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Medical History

Have you recently been exposed to environmental irritants or occupational hazards?

Yes

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Medical History

Are you immunocompromised (eg, on chemotherapy, steroids, HIV)?

Yes

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Medical History

Have you had recent travel to areas endemic for tuberculosis (TB) or histoplasmosis, or close contact with someone with TB?

Yes

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Current Symptoms

Nasal steroids such as fluticasone can also help some individuals by improving their symptoms however these should not be taken in certain situations. Do you have any of the following? (Select all that apply)

Recent nasal surgery or trauma

Current use of glucocorticoids such as prednisone or methylprednisolone

History of allergy reaction to glucocorticoids such as fluticasone (Flonase)

Cataracts or glaucoma

Nasal septal ulcers

Frequent nose bleeds

I don’t have any of these

Continue

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Submit

Medical History

Did you know that most upper respiratory infections are caused by viruses and clear up on their own within one to two weeks? Symptoms usually improve without antibiotics if given a little extra time. In fact, studies show worsening outcomes in some when they take an antibiotic. Because antibiotics can cause side effects such as gastrointestinal upset, Clostridioides difficile (C. Diff) infection, and contribute to the development of resistant bacteria, we generally reserve them for patients whose symptoms suddenly worsen or fail to improve after about ten days.

Yes I understand, I will monitor my symptoms and take the medications as recommended by the provider

I do NOT wish to continue

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Telemedicine Consent

Indication for Use: You are requesting evaluation and treatment for symptoms of an upper respiratory infection (URI), which may include nasal congestion, runny nose, cough, sore throat, and fever. URIs can be caused by various factors, including viral or bacterial infections, allergies, gastroesophageal reflux disease (GERD), and other potential causes.
Potential Benefits:

Relief of symptoms
Prevention of complications, such as secondary bacterial infections (e.g., sinusitis, bronchitis, pneumonia)
Improved overall respiratory comfort

Potential Side Effects and Risks: While treatments for URIs are generally safe, they may carry certain risks or side effects:

Symptomatic Treatments (analgesics, decongestants, cough suppressants):
- Drowsiness, dizziness, gastrointestinal upset
- Potential interactions with other medications
Antibiotics (if prescribed for suspected bacterial infection):
- Gastrointestinal disturbances (nausea, diarrhea)
- Allergic reactions, including rash or more severe reactions such as anaphylaxis
- Development of antibiotic resistance

Alternative Treatments:

Conservative management including rest, hydration, saline nasal irrigation, humidification, and over-the-counter symptom relief.
In-person evaluation by a healthcare provider for physical examination or further diagnostic testing if indicated.

Patient Responsibilities:

Provide accurate medical history and current symptom information.
Follow treatment recommendations and dosage instructions carefully.
Monitor and report any worsening or severe symptoms immediately to a healthcare provider.

Acknowledgment: By consenting to this telemedicine treatment, I acknowledge understanding of the benefits, potential risks, and side effects associated with the treatment of upper respiratory infections. I agree to follow the medical provider’s recommendations and understand when to seek further medical attention.

I have read and understand the consent and wish to proceed

I do NOT wish to proceed

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Verification

Please attest to the following confirming that all information you have provided to us is true and complete.

I verify that I am the patient and that I have answered the questions asked in this intake form. I confirm that I have reviewed and understood all the questions asked of me. I attest that the answers and information I have provided in this questionnaire is true and complete to the best of my knowledge. I understand that it is critical to my health to share complete health information with my doctor. I will not hold the doctor or affiliated medical practice responsible for any oversights or omissions, whether intentional or not, in the information that I provided.

I consent and wish to move forward

I do NOT wish to continue (End visit)

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We’re sorry — we’re not able to treat this case online

Based on the information you provided, this visit type requires in-person medical evaluation for safe and appropriate care.

What you were seeking help for:

• Upper Respiratory Infection (URI)

Why this happens

Some symptoms, medical history details, or risk factors mean a condition can’t be safely managed through telemedicine. A licensed provider must examine you in person to ensure the right diagnosis and treatment.

What to do next

Please visit a local urgent care, primary care clinic, or emergency department if your symptoms worsen.

Find another visit type

Cookie Settings

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URI questionnaire​​​​​​​​​​​​​​

Your Symptoms

Past Treatment

Your Symptoms

Past Treatment

Medical History

Medical History

Medical History

Current Symptoms

Medical History

Medical History

Current Symptoms

Medical History

What you were seeking help for:

Why this happens

HEY ENDRE, YOU CAN IGNORE ANYTHING BELOW THIS :)

Patient cookied :

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URI questionnaire