Admin: Chief Complaint -Urgent Care

FASTCARE TRIAGE

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Patient Name

First Last

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Date of Birth

Month

Day

Year

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Calculated Age

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Sex

PATIENT:

Who is bringing to the appointment?*

Mother

Father

Stepmother

Stepfather

Legal Guardian

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Sibling

Aunt

Uncle

Nanny

Caregiver

Other

PATIENT:

Who is completing the following triage questions for ?*

PATIENT:

Select ALL symptoms is experiencing.*

SELECT ALL THE SYMPTOMS THAT APPLY.

Abdominal Pain

Acid Reflux

Body Aches / Pain

Bowel / Stool Concerns

Chills

Congestion - Chest

Congestion - Nasal

Cough

Decreased Appetite

Difficulty Breathing

Ear Pain

Eye Concerns

Fatigue

Fever (100.4F+)

Headache

Nasal Drainage

Rash

Sore Throat

Vomiting

PATIENT:

Fever for how many days? (a fever is a temperature of 100.4F or greater)*

Not sure

When did the fever start?*

Today

Yesterday

2 days ago

3 days ago

4 days ago

5 days ago

6 days ago

7+ days ago

Not sure

When was last fever?*

Today

Yesterday

2 days ago

3 days ago

4 days ago

5 days ago

6 days ago

7+ days ago

Not sure

Highest recorded temperature taken by thermometer?*

How was the temperature taken?*

Rash for how many days?*

Not sure

Where is the rash located?*

Face

Scalp

Around eyes

Lips / mouth

Neck

Chest

Back

Abdomen

Left arm

Right arm

Left hand

Right hand

Left leg

Right leg

Left foot

Right foot

Diaper area / groin

Genitals

Head

Whole body

Cough for how many days?*

Not sure

Is the cough getting better or worse?*

Getting worse

Getting better

Got worse, then better

Got better, then worse

No change

Not sure

Chest congestion for how many days?*

Not sure

Nasal congestion for how many days?*

Not sure

When did nasal congestion start?*

Today

Yesterday

2 days ago

3 days ago

4 days ago

5 days ago

6 days ago

7+ days ago

2-4 weeks

2-4 months

4+ months

Not sure

Is the nasal congestion getting better or worse?*

Getting worse

Getting better

Got worse, then better

Got better, then worse

No change

Not sure

Is the nasal congestion worse during the day or night?*

Day

Night

Not sure

Is nasal congestion coming from both nostrils?*

Yes

Not sure

Is there any associated sneezing?*

Yes

Not sure

Is there any difficulty breathing associated with the nasal congestion?*

Yes

Not sure

Does have a known history of seasonal allergies?*

Yes

Not sure

Does have a known history of asthma?*

Yes

Not sure

Does have a known history of eczema?*

Yes

Not sure

Ear pain for how many days?*

Not sure

Which ear is causing pain?*

Left Ear

Right Ear

Both Ears

Has there been any drainage or discharge from the ear?*

Yes

Not sure

Has been swimming in the past 7 days?*

Yes

Not sure

Has seen ears, nose & throat (ENT) specialist?*

Yes

Not sure

Has been diagnosed with an ear infection within the past 6 months?*

Yes

Not sure

When was approximate date of ear the infection diagnosis?*

Month

Day

Year

What antibiotic was given?*

Amoxicillin

Amoxicillin-clavulanate

Cefdinir

Cefuroxime

Cefpodoxime

Ceftriaxone

Azithromycin

Clarithromycin

Clindamycin

Not sure

Does have ear tubes?*

Yes

Not sure

Sore throat for how many days?*

Not sure

Where does body hurt?*

Face

Scalp

Around eyes

Lips / mouth

Neck

Chest

Back

Shoulder

Arm

Elbow

Wrist

Hand

Finger

Leg

Knee

Ankle

Foot

Toe

Groin

Genitals

Head

Whole body

Which side?*

Left

Right

Both

Body aches / pain for how many days?*

Not sure

What makes body ache / pain better?*

Rest

Heat

Ice

Stretching

Movement

Massage

Pain medicine

Fluids

Nothing

Not sure

What makes body ache / pain worse?*

Movement or activity

Touch or pressure

Exercise

Sitting too long

Standing or walking

Cold weather

Fatigue

Stress

Nothing

Not sure

Do the body aches / pain seem worse while running temperature greater than 100.4?*

Yes

Not sure

Any joint swelling?*

Yes

Not sure

What time of the day does it hurt?*

Morning

Afternoon

Evening

Night

During sleep

Constant

Intermittent

Not sure

Has there been any eye drainage / discharge?*

Yes

Not sure

Eye drainage / discharge for how many days?*

Not sure

When did the eye drainage / discharge start?*

Today

Yesterday

2 days ago

3 days ago

4 days ago

5 days ago

6 days ago

7+ days ago

Not sure

Is eye drainage / discharge clear or yellow?*

Clear

Yellow

Both Eyes

Which eye is of concern?*

Left Eye

Right Eye

Both Eyes

Has there been any crusting from the eye?*

Yes

Not sure

Has there been any eye pain?*

Yes

Not sure

Has there been any eyelid swelling?*

Yes

Not sure

Has there been any eye watering:?*

Yes

Not sure

Has the eye been itchy?*

Yes

Not sure

Is there redness in the white part of the eye?*

Yes

Not sure

Has there been a change in vision?*

Yes

Not sure

Has there been any known injury?*

Yes

Not sure

Does wear glasses?*

Yes

Not sure

Does the patient wear contact lenses?*

Yes

Not sure

Nasal drainage for how many days?*

Not sure

Chills for how many days?*

Not sure

When did the chills start?*

Today

Yesterday

2 days ago

3 days ago

4 days ago

5 days ago

6 days ago

7+ days ago

Not sure

Difficulty breathing for how many days?*

Not sure

Any shortness of breath?*

Yes

Not sure

When do you have shortness of breath?*

Constantly

Intermittently

Not sure

Is having trouble breathing, such as breathing fast, using extra muscles (ribs or neck pulling in), flaring nostrils, grunting, or head bobbing?*

Yes

Not sure

Any pain with breathing?*

Yes

Not sure

Any "barky" (stridor) sounds while coughing?*

Yes

Not sure

Is the coughing worse at night?*

Yes

Not sure

Any wheezing?*

Yes

Not sure

Has a doctor ever diagnosed with wheezing?*

Yes

Not sure

Has needed inhaled medication by a nebulizer or inhaler in the past?*

Yes

Not sure

Has used any inhaled medications (breathing treatments) with this illness?*

Yes

Not sure

Which type of treatment(s) did receive with this illness?*

Nebulizer with mask

Inhaler

Both

Not sure

When was the first treatment with a nebulizer with mask?*

Today

Yesterday

2 days ago

3 days ago

4 days ago

5 days ago

6 days ago

7+ days

Not sure

When was the first treatment with an inhaler?*

Today

Yesterday

2 days ago

3 days ago

4 days ago

5 days ago

6 days ago

7+ days

Not sure

When was the last treatment with a nebulizer with mask?*

Today

Yesterday

2 days ago

3 days ago

4 days ago

5 days ago

6 days ago

7+ days

Not sure

What time was the last dose of inhaled medication using a nebulizer with mask?*

When was the last treatment with an inhaler?*

Today

Yesterday

2 days ago

3 days ago

4 days ago

5 days ago

6 days ago

7+ days

Not sure

What time was the last dose of inhaled medication using an inhaler?*

How many breathing treatments in the past 24 hours?*

Not sure

What is the name of the inhaled medication?*

Albuterol

Levalbuterol

Albuterol + Ipratropium (DuoNeb)

Budesonide (Pulmicort)

Inhaled steroid (Flovent / Pulmicort)

Has been seen in the ED or hospitalized for difficulty breathing in the past?*

Yes

Not sure

Is followed by an allergist or pulmonologist?*

Yes

Not sure

Vomiting for how many days?*

Not sure

Any mucus in the stools?*

Yes

Not sure

Any blood in the stools?*

Yes

Not sure

Has had any constipation?*

Yes

Not sure

Constipation for how many days?*

Not sure

Has had any diarrhea?*

Yes

Not sure

Diarrhea for how many days?*

Not sure

How many episodes of diarrhea has had in the past 24 hours?*

1-2

3-5

6-9

10+

Not sure

Is the diarrhea watery?*

Yes

Not sure

Is tolerating small amounts of clear liquid often?*

Yes

Not sure

How many times has urinated in the past 24 hours?*

1 time

2 times

3 times

4 times

5 times

6 times

7+ times

Not sure

Does have sunken eyes?*

Yes

Not sure

Does have dry mouth?*

Yes

Not sure

Does have decreased tears?*

Yes

Not sure

Has ever seen a gastrointestinal (GI) specialist?*

Yes

Not sure

Has consumed seafood or sushi in the past 2 weeks?*

Yes

Not sure

Has taken any antibiotics in the past month?*

Yes

Not sure

What antibiotic did take?*

Has had any exposure to animals, livestock or petting zoos in the past 2 weeks?*

Yes

Not sure

Has traveled in the past 2 weeks?*

Yes

Not sure

Is there anyone who lives with have similar symptoms?*

Yes

Not sure

When did the decreased appetite start?*

Is drinking liquids normally?*

Yes

Not sure

How many ounces of water does consume per day?*

None

Less than 8 oz

8–16 oz

17–24 oz

25–32 oz

33–48 oz

49–64 oz

More than 64 oz

Not sure

How many ounces of milk does consume per day?*

None

Less than 8 oz

8–16 oz

17–24 oz

25–32 oz

33–48 oz

49–64 oz

More than 64 oz

Not sure

How many ounces of caffeine (tea, coffee, energy drink) does consume per day?*

None

Less than 8 oz

8–16 oz

17–24 oz

25–32 oz

33–48 oz

49–64 oz

More than 64 oz

Not sure

How many ounces of juice does consume per day?*

None

Less than 8 oz

8–16 oz

17–24 oz

25–32 oz

33–48 oz

49–64 oz

More than 64 oz

Not sure

Does skip meals?*

Yes

Not sure

Would you describe as a picky eater?*

Yes

Not sure

Are there any food restrictions at home?*

Yes

Not sure

Does have any problems with pain with urination or change in urinary frequency?*

Yes

Not sure

Has been seen by a GI specialist in the past?*

Yes

Not sure

Has been seen by a nutritionist or feeding specialist in the past?*

Yes

Not sure

Are you concerned about the patient's weight?*

Yes

Not sure

Headache for how many days?*

Not sure

What was the age of onset of headaches?*

Not sure

How often does the headache occur per week?*

Once per week

2-3 times per week

4-6 times per week

Not sure

How many headaches has had the last month in total?*

Does the headache severity worsen as time goes on?*

Yes

Not sure

How long does the headache last?*

One hour or less

2 hours

3 hours

4 hours

5 hours

6 hours

7+ hours

Not sure

Are there any physical sensations (aura) that the headache is about to occur?*

Yes

Not sure

What time of the day does the headache usually occur?*

Morning

Afternoon

Evening

Night

Not sure

Does the headache wake you from your sleep?*

Yes

Not sure

What does the headache feel like?*

Throbbing

Pulsating

Dull

Aching

Squeezing

Not sure

Where is the headache located?*

Front

Back

Left

Right

All over

Not sure

Does the headache (radiate) move from one location to the other?*

Yes

Not sure

Does anything make the headache worse?*

Yes

Not sure

What makes the headache worse?

Certain foods

Odors

Bright lights

Noise

Lack of sleep

Exercise

Stress

Laying down

Does anything help the headache go away?*

Yes

Not sure

What helps the headache go away?

Dark room

Quiet room

Cool compress

Sleep

Drinking water

OTC medicine

Any changes in weight?*

Yes

Not sure

Any changes in overall vision?*

Yes

Not sure

Any associated abnormal gait?*

Yes

Not sure

Any associated confusion?*

Yes

Not sure

Any associated nausea or vomiting?*

Yes

Not sure

Any associated dizziness, numbness of arms/legs or loss of consciousness (blacking out)?*

Yes

Not sure

Any associated sick symptoms such as fever, nasal congestion, cough, stiff neck?*

Yes

Not sure

Any recent diagnosis of an ear infection, throat infection, sinusitis or dental abscess?*

Yes

Not sure

Any recent history of car accidents, head trauma or concussions?*

Yes

Not sure

Any new medications, OTC medications, Vitamins, Herbal remedies, nutritional supplements?*

Yes

Not sure

Any personal use or second hand exposure to tobacco products or vaping?*

Yes

Not sure

Do these headaches prevent the child from participating in things they enjoy?*

Yes

Not sure

Any recent changes in home, school, extracurricular activities?*

Yes

Not sure

Has had frequent school absences?*

Yes

Not sure

Any recent changes in sleep?*

Yes

Not sure

Any recent changes in appetite?*

Yes

Not sure

Any known stressors?*

Yes

Not sure

Any family history of headaches?*

Yes

Not sure

Fatigue for how many days?*

Not sure

Abdominal pain for how many days?*

Not sure

Where is the abdominal pain located?*

Left

Right

Middle

Upper

Lower

Not sure

What makes the abdominal pain better?*

Rest

Heat

Ice

Stretching

Movement

Massage

Pain medicine

Fluids

Nothing helps

Not sure

What makes abdominal pain worse?*

Movement or activity

Touch or pressure

Exercise

Sitting too long

Standing or walking

Cold weather

Fatigue

Stress

Nothing makes it worse

Not sure

Is pain associated with nausea?*

Yes

Not sure

Is pain associated with vomiting?*

Yes

Not sure

When was FIRST episode of vomiting?*

Today

Yesterday

2 days ago

3 days ago

4 days ago

5 days ago

6 days ago

7+ days

Not sure

When was LAST episode of vomiting?*

Today

Yesterday

2 days ago

3 days ago

4 days ago

5 days ago

6 days ago

7+ days

Not sure

How many vomiting episodes in the past 24 hours?*

Not sure

Does the abdominal pain change with eating?*

Yes

Not sure

Any change in overall appetite?*

Yes

Not sure

Is pain worse when laying flat?*

Yes

Not sure

Does pain move to the back or side?*

Yes

Not sure

Is experiencing any known weight loss?*

Yes

Not sure

Does have any diarrhea?*

Yes

Not sure

Does have any constipation?*

Yes

Not sure

What is the typical frequency of stool?*

3 or more times per day

1–2 times per day

Every other day

Every 3–4 days

Once per week or less

Not sure

When was the patient's last stool?*

Today

Yesterday

2 days ago

3 days ago

4 days ago

5 days ago

6 days ago

7+ days ago

Not sure

Does have any blood or mucus in stool?*

Yes

Not sure

Does have any stooling incontinence?*

Yes

Not sure

Does have any pain with urination?*

Yes

Not sure

Does have any change in urinary frequency?*

Yes

Not sure

Does have any urinary incontinence?*

Yes

Not sure

Does have any known history of previous urinary tract infections (UTI)?*

Yes

Not sure

Has experienced any back pain?*

Yes

Not sure

Has ever seen a gastrointestinal (GI) specialist?*

Yes

Not sure

Has experienced any vaginal redness?*

Yes

Not sure

Has experienced any vaginal discharge?*

Yes

Not sure

Has experienced any vaginal sores?*

Yes

Not sure

What is the patient's length of menstrual period?*

1–2 days

3–4 days

5–6 days

7–8 days

8+ days

Not sure

Has not started menstruating

What is the patient's frequency of menstrual periods?*

About every 3 weeks

About every 4 weeks

About every 5 weeks

Longer than 5 weeks

Irregular

Not sure

When was the patient's last menstrual period?*

Does have any heavy menstrual periods?*

Yes

Not sure

Does have any painful menstrual periods?*

Yes

Not sure

Acid reflux for how many days?*

Not sure

Where is pain located?*

Upper abdomen

Right side of abdomen

Left side of abdomen

Lower abdomen

What makes pain better?*

Drinking

Eating

Urinating

Pooping

Rest

Nothing

Not sure

What makes pain worse?*

Drinking

Eating

Urinating

Pooping

Laying flat

Movement

Nothing

Not sure

Does pain move to back or side?*

Yes

Not sure

Is pain worse when laying flat?*

Yes

Not sure

Any increase in belching?*

Yes

Not sure

Any increase in flatulence?*

Yes

Not sure

Does pain change with eating?*

Yes

Not sure

Is pain worse with any of these?*

Citrus

Caffeine

Red sauces

Spicy foods

Carbonated drinks

Not sure

Any change in overall appetite?*

Yes

Not sure

Any known weight loss?*

Yes

Not sure

Is pain associated with nausea?*

Yes

Not sure

Is pain associated with vomiting?*

Yes

Not sure

When was FIRST episode of vomiting?*

Today

Yesterday

2 days ago

3 days ago

4 days ago

5 days ago

6 days ago

7+ days

Not sure

When was LAST episode of vomiting?*

Today

Yesterday

2 days ago

3 days ago

4 days ago

5 days ago

6 days ago

7+ days

Not sure

How many vomiting episodes in the past 24 hours?*

Not sure

Any associated back pain?*

Yes

Not sure

Any change in urinary frequency?*

Yes

Not sure

Any pain with urination?*

Yes

Not sure

Does have any diarrhea?*

Yes

Not sure

Does have any constipation?*

Yes

Not sure

Any stooling incontinence?*

Yes

Not sure

Any blood or mucus in stool?*

Yes

Not sure

What is the typical frequency of stool?*

3 or more times per day

1–2 times per day

Every other day

Every 3–4 days

Once per week or less

Not sure

When was the patient's last stool?*

Today

Yesterday

2 days ago

3 days ago

4 days ago

5 days ago

6 days ago

7+ days

Not sure

Has ever seen a gastrointestinal (GI) specialist?*

Yes

Not sure

Acid reflux for how many days?*

Not sure

Does feed well?*

Yes

Not sure

Can you tell when is hungry?*

Yes

Not sure

Do you have problems burping ?*

Yes

Not sure

Do you burp mid feeding and end of feeding?*

Yes

Not sure

Do you keep upright for 20 minutes following feedings?*

Yes

Not sure

Do you provide tummy time for 5-10 minutes prior to feeds during the day supervised on a blanket on the floor to encourage digestion and passing of flatulence?*

Yes

Not sure

How long does it take to feed ?*

Less than 5 mins

5 mins

10 mins

15 mins

20 mins

25 mins

30 mins

30+ mins

Not sure

Is fed formula?*

Yes

Not sure

What type of formula?*

Similac Advance

Similac 360 Total Care

Similac Sensitive

Similac Alimentum

Similac Soy Isomil

Enfamil NeuroPro Infant

Enfamil Infant

Enfamil Gentlease

Enfamil Nutramigen

Gerber Good Start GentlePro

Gerber Good Start SoothePro

Enfamil ProSobee (Soy)

Similac Soy Isomil

Neocate

EleCare

PurAmino

Store brand formula

Not sure

How long have you fed this type of formula?*

1 week or less

2 weeks

3 weeks

1 month

2 months

3 months

4 months

5 months

6 months

7 months

8 months

9 months

10 months

11 months

Not sure

Have you changed the type of formula you are feeding in the past?*

Yes

Not sure

What types have you trialed in the past?*

Yes

Not sure

If is formula fed what percentage of feeds is formula in 24 hours?*

5% or less

10%

15%

20%

25%

30%

35%

40%

45%

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

Not sure

If feeding by bottle what type of bottle is used?*

Standard narrow neck bottle

Wide neck bottle

Anti-colic vent bottle

Silicone bottle

Glass bottle

Disposable liner bottle

Specialty feeding bottle

Not sure

If feeding by bottle what flow rate nipple is used?*

Level 0

Level 1

Level 2

Level 3

Level 4

Not sure

What is feeding frequency of milk during the day?*

Every 2-3 hours

Every 2-4 hours

Every 3-4 hours

Every 3-5 hours

Every 4-5 hours

Every 4-6 hours

Not sure

What is feeding frequency of milk during the night?*

Every 2-3 hours

Every 2-4 hours

Every 3-4 hours

Every 3-5 hours

Every 4-5 hours

Every 4-6 hours

Not sure

Any difficulty with latching or positioning if nursing?*

Yes

Not sure

Does make clicking noises while sucking to drink milk?*

Yes

Not sure

Does milk spill out of your child’s mouth while nursing or taking a bottle?*

Yes

Not sure

Any spitting up, back arching, coughing or choking during or following feedings?*

Yes

Not sure

How many wet diapers has had the past 24hours?*

1-2

3-4

5-6

7 or more

Not sure

How many dirty diapers has had the past 24hours?*

1-2

3-4

5-6

7 or more

Not sure

What is the frequency of dirty diapers for ?*

Once per day

2-3 times per day

4-6 times per day

Not sure

Any blood or mucus in the stools?*

Yes

Not sure

Have you provided any probiotics to to help with digestion?*

Yes

Not sure

What probiotics?*

BioGaia Protectis Drops

Culturelle Baby Drops

LoveBug Infant Drops

Culturelle Kids

Garden of Life Kids Probiotic

FlorastorKids

SmartyPants Kids Probiotic

Renew Life Kids Ultimate Flora

NOW BerryDophilus Kids

Klaire Labs Children’s Chewable Probiotic

Have you provided any antacids such as Famotidine, Zantac or Prevacid?*

Yes

Not sure

Has started baby foods or soft solids?*

Yes

Not sure

What foods have they tried?*

Infant cereal (rice)

Infant cereal (oatmeal)

Infant cereal (multigrain)

Fruits

Vegetables

Meats

Cheese

Yogurt

Eggs

Peanut / nut products

Crackers

Not sure

How often do you offer baby foods or soft solids?*

Once per day

Twice per day

Three times per day

Four times per day

More than four times per day

Not sure

Any change in feeding comfort or spitting up after baby foods or soft solids?*

Yes

Not sure

PATIENT:

Has taken any medications, supplements, or home remedies for this illness?*

Yes

Not sure

Which medications, supplements or home remedies?*

When was last dose of Acetaminophen (Tylenol) today?*

What was the amount of Acetaminophen (Tylenol) given?*

When was last dose of Ibuprofen (Motrin / Advil) today?*

What was the amount of Ibuprofen (Motrin / Advil) given?*

Are there any ill contacts at home?*

Yes

Not sure

Has there been any travel in the past 2 weeks?*

Yes

Not sure

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MRN

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Provider

Acetaminophen (Tylenol)
Ibuprofen (Motrin / Advil)
Cetirizine (Zyrtec)
Loratadine (Claritin)
Fexofenadine (Allegra)
Diphenhydramine (Benadryl)
Honey (for cough)
Ondansetron (Zofran)
Prednisolone / Prednisone
Amoxicillin
Amoxicillin-Clavulanate (Augmentin)
Azithromycin
Cephalexin (Keflex)
Cefdinir (Omnicef)
Cefixime
Clindamycin
Trimethoprim-Sulfamethoxazole (Bactrim / Septra)
Metronidazole (Flagyl)
Montelukast (Singulair)
Famotidine (Pepcid)
Omeprazole (Prilosec)
Lansoprazole (Prevacid)
Polyethylene Glycol (Miralax)
Fluconazole (Diflucan)
Nystatin oral suspension
Oseltamivir (Tamiflu)
Acyclovir
Pedialyte
Simethicone gas drops (Mylicon / Little Remedies Gas Relief)
Gripe water
Saline nasal drops or spray
Vitamin D drops
Multivitamin
Multivitamin drops
Iron supplement / iron drops
Probiotic / probiotic drops
Bacitracin ointment
Neomycin / Polymyxin / Bacitracin (Neosporin)
Mupirocin (Bactroban)
Hydrocortisone cream
Triamcinolone cream
Clotrimazole (Lotrimin)
Miconazole (Micatin / Monistat)
Ketoconazole cream
Nystatin cream
Zinc oxide (Desitin / Triple Paste)
A&D ointment
Calamine lotion
Diphenhydramine cream
Petroleum jelly (Vaseline)
Aquaphor
Eucerin
CeraVe
Herbal remedies
Homeopathic remedies
None
Not sure
Other medication or remedy