Telehealth Consultation Form

I. Patient Demographics and Contact Information

First Name:

Last Name:

Date of Birth:

Gender:

Street Address:

City:

State/Province:

Postal/Zip Code:

Phone Number (Primary):

Phone Number (Secondary):

Email:

Preferred Language:

Emergency Contact Name:

Emergency Contact Relationship:

Emergency Phone Number:

II. Technical Readiness and Consent

	Actionable Item	Tick if Yes	Notes
	A	B	C
1	Do you have a stable internet connection?
2	Do you have a device with a camera and microphone?
3	Are you comfortable using video conferencing software?
4	Do you have a private and quiet space for the consultation?
5	Do you understand that this is a telehealth consultation and that physical examination may be limited?
6	Do you consent to receive telehealth services?
7	Do you understand potential limitations of telehealth, including technical difficulties or the need for an in-person visit?

What device will you be using for this telehealth appointment?

What video conferencing platform will you be using?

Do you consent to the recording of this consultation if necessary for medical records or quality assurance?

Yes

Not Applicable

III. Reason for Consultation and Systems

What is the primary reason for your telehealth consultation today?

Please describe your symptoms in detail, including when they started and how they have changed.

What are your current concerns or questions?

How severe are your symptoms?

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Are you experiencing any of the following? (List common symptoms relevant to your practice, e.g., fever, cough, pain, etc.)

Have you taken any medications or treatments for these symptoms?

Yes

What medications or treatments are they?

When?

IV. Medical History

List any current medical conditions.

List any past medical conditions or surgeries.

List any current medications, including dosage and frequency.

	Medication Name	Dosage	Frequency
	A	B	C
1
2
3
4
5
6
7
8
9
10

List any allergies (medications, food, environmental).

Do you have any history of mental health conditions?

Yes

Please specify.

Family medical history (any significant conditions that run in your family)

Do you smoke?

Yes

Do you use recreational drugs?

Yes

Do you consume alcohol?

Yes

How often?

V. Vital Signs

Temperature:

Blood Pressure:

Pulse/Heart Rate:

Weight:

VI. Follow-Up and Expectations

What are your expectations for this telehealth consultation?

Do you understand the process for follow-up appointments or tests?

Yes

Do you have any questions before we begin, and what are they?

VII. Additional Notes

Form Template Instructions

Please remove Form Template Instructions before publishing this form

Strengths:

Comprehensive Coverage:

The form covers essential areas: demographics, technical readiness, consent, medical history, vital signs, follow-up, and provider notes. This ensures a holistic view of the patient.

Structured Organization:

The form is logically organized into sections, making it easy for patients and providers to navigate.

Flexibility:

The template provides guidance for both digital and paper formats, catering to diverse needs.

Emphasis on Consent:

The inclusion of explicit consent questions highlights the importance of patient autonomy and legal compliance.

Focus on Technical Readiness:

Addressing technical requirements upfront helps minimize disruptions during the consultation.

Provider Notes Section:

Having a dedicated area for provider notes is essential for accurate record-keeping.

To configure an element, select it on the form.

To add a new question or element, click the Question & Element button in the vertical toolbar on the left.