Telehealth Clinical Assessment Form
Patient Information
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Marital Status
Single
Married
Divorced
Widowed
Occupation
Educational Attainment
Medical Data
Complaint
Diagnosis
Height (ft)
Weight (lbs)
Temperature (C)
Blood Pressure (mmHg)
Pulse Rate (bpm)
Respiratory Rate (bpm)
Do you have any allergies?
Food
Environmental
Medication
No allergies are known
Other
Are you taking any medications currently?
Any meds including supplements
Existing Medical Problems/Conditions
Previous hospitalization
Provide the reason and treatment
Family History Illnesses
Asthma
Cardiovascular Disease
Diabetes Mellitus
Hypertension
Tuberculosis
Other
Assessment
System Review
Rows
Normal
Not Normal
Notes/Remarks
Sensory (Eyes, ears, nose, throat)
1
2
Musculoskeletal (Mobility)
3
4
Integumentary (Rashes, irritation, pale)
5
6
Neurovascular (Paint, seizures, sensation)
7
8
Circulatory (Skin, edema)
9
10
Respiratory (Shortness of breath)
11
12
Dental (Dentures)
13
14
Psychosocial (Hallucinations, delusions)
15
16
Nutrition (Diet, weight change, swallowing)
17
18
Elimination (Constipation, incontinence)
19
20
Additional comments
Goals of Care
Management Plan
Healthcare Provider Name
First Name
Last Name
Healthcare Provider's Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
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