What was your sex assigned at birth? We ask all of our patients this question to ensure we provide them with safe and effective care. We include all identities. *

Male
Female

What do you need help with today? Select one of the following common problems. *

Cold or flu (cough, sore throat, congestion, etc.)
Concerned about the coronavirus / COVID-19
Headache
Eye problems (i.e. conjunctivitis)
Urinary tract infection
Seasonal allergies (sneezing, congestion, etc.)
Skin rash, hives, or sores
Acid reflux
Asthma: medication replacement
Migraine: medication replacement

Do you have any of the following symptoms? *

Chest pain after eating.
I wake up in the middle of the night with burning in my chest.
Burning in the chest if you lie down after eating
Acid or vomiting sensation from the stomach to the mouth in the back of the throat.
Difficulty or pain swallowing or feeling like food is stuck in the chest.
Excessive belching
Heartburn
Sore throat
Gas bloating or an upset stomach
Long-lasting cough
Asthma
Rough voice with the need to clear throat frequently.
Other

What other acid reflux symptoms are you experiencing? *

Do any of the following currently apply to you? Acid reflux *

Bloating or abdominal distension
Pain when swallowing
Recurring vomiting or vomiting blood.
Constipation, diarrhea, or changes in bowel habits.
Deep pressure at the base of your neck
Blood in stools or dark tarry stools
Jaundice (yellow skin)
Unexplained weight loss
Anemia
None apply

We are restocking well-controlled asthma medications, short-term only, for patients without signs or symptoms that worsen. We are not managing your underlying condition or changing the dose or frequency of your medications. You should inform your primary care provider of this visit and follow up with your primary care provider. By continuing, you acknowledge and agree that you meet these eligibility requirements and conditions, and wish to continue refilling your asthma medication (s). *

I understand and wish to continue

Do any of the following currently apply to you? *

Chest tightness
Fever
Head trauma
More frequent headaches
Neck stiffness
Severe wheezing at rest
Difficulty breathing
Worsening headaches
None apply

Do any of the following currently apply to you? Select all that apply. ASTHMA *

Difficulty breathing
Chest tightness
Severe wheezing at rest
Fever
None apply

What was your recent temperature reading? This helps your doctor recommend the appropriate treatment. *

Have you been diagnosed with tension headaches? *

What triggers your headache episodes? *

Does it feel like your usual headache? *

Do you have any of the following symptoms? Eyes Select all that apply. *

Crisp eyes
Itch
Slight blurring
Redness
Pus-like discharge
Watery discharge
Blister-like rash near the eye
Annoyed by the lights (photophobia)
Vision change
Distorted or fixed pupil
Eye pain
Feeling of something in my eye
Fever
Severe headache with nausea.
Sight loss
Other

Do you have any of the following symptoms? Select all that apply. Acne *

Blisters
Burning
Scabs
Hair loss
Urticaria
Itch
Open wound
Rash
Redness
Scalping
Swelling of the face or eyes
Warm to the touch
Other

What areas of your body are affected? *

Head / scalp
Face
Neck
Chest
Abdomen
Back
Arms
Hands
Buttocks
Genitals
Upper legs
Lower legs
Ankles / Feet

How long have you been experiencing symptoms? *

Have you been around someone with a contagious skin problem? *

What medications did you try? Include the name and dosage of each medication and whether it was effective or not. Skin* *

What other skin symptoms are you experiencing? *

What other eye symptoms are you experiencing? *

How long have you been experiencing symptoms? *

Rate your general discomfort from 0 to 10. Rash *

[0]
1-3
4-7
8-10

Have you ever had this skin problem? *

Rate your general discomfort from 0 to 10. Eyes *

[0]
1-3
4-7
8-10

Have you taken anything to relieve your symptoms? Eye *

Have you taken anything to relieve your symptoms? Acne *

What medications did you try? Include the name and dosage of each medication and whether it was effective or not. *

Do any of the following currently apply to you? Select all that apply. *

Glaucoma
History of eye surgery
Occupation: Metalworker / Welder
None apply

Do you have any of the following urinary symptoms? Select all that apply. *

Blood in the urine
Fever
Frequent urination
Increased vaginal discharge
Pain in the lower abdominal area
Pain or burning when urinating
Smelly urine
Urgent need to urinate
Vaginal itching
Back or flank pain
Shaking chills
Extreme fatigue
Nausea or vomiting
Pelvic pain
Other

Do you think you have the seasonal flu? *

Have you been exposed to someone diagnosed with seasonal flu? *

Have you had a flu shot this year? *

Do you have any of the following symptoms? *

Congestion
Cough
Headache
Fever
General aches and pains
Throat pain
Sinus pain
Sneezing
Stuffy or runny nose
Tiredness
Weakness
White spots on the tonsils
Other

Select all that apply

What other seasonal allergy symptoms? *

How long have you been experiencing symptoms? *

If you are concerned about exposure or symptoms related to COVID-19, use our FREE SELF-ASSESSMENT tool. If it is an emergency or you have severe or urgent symptoms such as a very high temperature (> 100.5), shortness of breath with shortness of breath, severe pain or weakness, or bleeding, call 911 or seek care in person immediately. *

Go to the self-assessment.

Do you wear contact lenses? *

What medications did you try? Include the name and dosage of each medication and whether it was effective or not. Acne *

Do any of the following currently apply to you? Select all that apply. (Acne) *

Diabetes
Liver problems
Immunosuppressed
None apply

Are your symptoms associated with food? *

Do your symptoms occur at night? *

Are your symptoms worse while lying down? *

Does your reflux wake you up at night? *

How many times a week do you experience symptoms? *

Less than 3 times a week
More than 3 times a week

Have you taken any medications to try to relieve acid reflux? *

What medications did you try? Include the name and dosage of each medication and whether it was effective or not. *

When was the last time you took the medications? *

How long have you been taking medication? *

Do any of the following currently apply to you? acid *

Erosive esophagitis
Barrett's esophagus or first-degree relative with Barrett's esophagus
Liver problems
Kidney problems
Porphyria
Cancer
Anemia
None apply

What feels different about this headache? *

What symptoms do you have? Select all that apply. *

Dull aching headache
Pressure or tightness in the forehead
Scalp sensitivity
Tenderness in the shoulders or neck
Nausea or vomiting
Physical movement makes headache worse
Visual / auditory disturbances
Other

Are you experiencing any of the following symptoms with your cough? *

Severe pain
With blood
Phlegm
None apply

What was your most recent temperature reading? This helps your doctor recommend the appropriate treatment. *

How would you describe your headache? *

Mild
Severe

How would you describe your sore throat? *

Mild
Severe

What other cold or flu symptoms are you experiencing? *

Do you have any of the following symptoms? #2 *

Blue tint to the skin
Chest pain
Labored breathing
Difficulty swallowing food or liquids.
Double vision
Drooling
Neck stiffness or pain
Voice muffled
Fast breathing
Swelling around the eyes
Swelling on one side of the neck.
Wheezing
None apply

Press continue to end the patient intake (eye) *

Continue

Press continue to end patient intake (acid) *

Continue

Press continue to end patient intake *

Continue

How long have you been experiencing symptoms? *

0-2 days
2-3 days
More than 3 days

Rate your general discomfort from 0 to 10. *

[0]
1-3
4-7
8-10

Have you tried any medications for your symptoms? *

Have you taken any medications to try to relieve your headache? *

What medications did you try? Include the name and dosage of each medication and whether it was effective or not. *

Do any of the following apply to you? Select all that apply. *

Asthma or other lung problems
Chronic Obstructive Pulmonary Disease (COPD)
Difficulty breathing, not related to nasal congestion.
Severe and persistent chest pain
In the COVID-19 outbreak area 2 weeks before symptoms appeared
Near anyone being tested for the COVID-19 coronavirus
None apply

Are you currently wheezing? Wheezing is a high-pitched whistle that occurs when you breathe. *

Do you have any medical conditions? *

What medical conditions do you have? *

Have you had any surgery or hospitalization? *

What surgeries or hospitalizations have you had? *

Are you taking any prescription, over-the-counter medications, supplements, or herbal remedies? *

What other prescription drugs, over-the-counter drugs, supplements, or herbal remedies are you taking? Give the name and dosage of each. *

Do you have any allergies to foods, dyes, medications, or anything else? *

What allergies do you have? *

This is your first message to your doctor. Introduce yourself and ask your doctor any questions you have about treatment. Feel free to include anything else you want them to know about your illness. *

Please enter you Date of Birth... Month- Date-Year.

Name *

First

Last

Numbers