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

Do you have a stable internet connection?
 
Do you have a device with a camera and microphone?
 
Are you comfortable using video conferencing software?
 
Do you have a private and quiet space for the consultation?
 
Do you understand that this is a telehealth consultation and that physical examination may be limited?
 
Do you consent to receive telehealth services?
 
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?

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?

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?

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

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

List any allergies (medications, food, environmental).

Do you have any history of mental health conditions?

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

Do you smoke?

Do you use recreational drugs?

Do you consume alcohol?

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?

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

VII. Additional Notes

Form Template Instructions

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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.
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