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Important Notice Regarding Body Type Me & S.I.C. Consults
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Initial Daily Vitals Virtual Intake Form
S.I.C. Daily Vitals Virtual Intake Form
S.I.C. Daily Vitals Virtual Intake Form
Instructions
This form is required to be filled out once per day in accordance to your scheduled followup. If these forms are not completed, this may impact your scheduled followup.
Date
Name
Name
First
First
Last
Last
What sex was originally listed on your birth certificate?
Male
Female
Email
Morning Data
Please record this information in the morning when you wake up.
Do you have chills or fever?
*
Yes
No
Please provide your temperature:
*
Have you been perspiring?
*
Yes
No
If yes, are you prespiring mildly, moderately, or profusely?
*
Mild Sweating
Moderate Sweating
Profuse Sweating
How is your appetite on a scale of 0-10, with 10 being very hungry?
*
0
1
2
3
4
5
6
7
8
9
10
How is your thirst on a scale of 0-10, with 10 being very thirsty?
*
0
1
2
3
4
5
6
7
8
9
10
What is your blood pressure?
What is your pulse oximeter reading?
Evening Data
Please record this information in the evening before you go to bed.
Do you have chills or fever?
*
Yes
No
Please provide your temperature:
*
Have you been perspiring?
*
Yes
No
If yes, are you prespiring mildly, moderately, or profusely?
*
Mild Sweating
Moderate Sweating
Profuse Sweating
How is your appetite on a scale of 0-10, with 10 being very hungry?
*
0
1
2
3
4
5
6
7
8
9
10
How is your thirst on a scale of 0-10, with 10 being very thirsty?
*
0
1
2
3
4
5
6
7
8
9
10
What is your blood pressure?
What is your pulse oximeter reading?
General Daily Information
How many times did you void (urinate) today?
*
0
1
2
3
4
5
6
7
8
9
10
How many bowel movements did you have today?
*
0
1
2
3
4
5
6
7
8
9
10
Were you in pain today?
*
Yes
No
How much pain were/are you in on a scale from 1-10, with 10 being extreme pain?
*
1
2
3
4
5
6
7
8
9
10
Where are you having pain? Please choose all that apply.
*
Front
Sides
Top
Back of Head
Neck
Hand/Wrist/Forearm/Upper Arm
Shoulders
Chest with Cough
Chest without Cough
Upper/Middle/Lower Back
Epigastric Pain (Stomach)
Abdominal Pain
Hip pain
Leg pain
Knee pain
Lower leg pain
Ankle pain
Foot pain
Do you have any whitish discharge when not on your menstral cycle or before your menstral cycle?
*
Yes
No
Is the discharge thick or thin?
*
Thick
Thin
Is the thick discharge sticky?
*
Yes
No
Is the thin discharge profuse and watery?
*
Yes
No
How much energy did you have today on a scale from 0-10, with 10 being high energy?
*
0
1
2
3
4
5
6
7
8
9
10
Submit
If you are human, leave this field blank.