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Informed Consent
I understand that an online medical visit can be a great option for non-emergency medical issues and not ideal for severe or life-threatening illnesses. I understand that treatments offered on CallonDoc.com are on the basis of clinical judgement, in the absence of a complete physical examination. I agree to follow up with a doctor for an in-person evaluation or seek emergency care if my symptoms worsen or do not improve in a timely manner.
PROCEED
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Are you alert and oriented ?
Yes
No
STOP! You must be alert and oriented to proceed
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Are you allergic to any drug?
Yes
No known drug allergy
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What medication (s) are you allergic to?
Azithromycin
Metronidazole
Cefixime
Doxycycline
Doxycycline
Lisinopril
Azithromycin
Norvasc
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Do you have any underlying medical condition?
Yes
No
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Select medical condition
Heart disease
Heart disease
CHF
Chest pains
Other
Hypertension
Liver disease
Kidney disease
Diabetes
High cholesterol
Thyroid disorder
Psychiatric condition
Anxiety
CHF
Chest pains
Other
Other
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Are you currently taking medications? *
To analyse for drug to drug interaction
Yes
No
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What medications are you currently taking?
Azithromycin
Metronidazole
Cefixime
Doxycycline
Doxycycline
Lisinopril
Azithromycin
Norvasc
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Pregnancy Evaluation
Menstrual status
I'm currently on my period
I'm pregnant
I'm NOT currently on my cycle
I have not had my first menstrual cycle
I no longer have menstrual periods
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Are you currently breastfeeding?
Yes
No
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Have you had surgery in the past?
Yes
No
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What surgeries did you have?
Angioplasty
Appendectomy
Breast biopsy
Cataract Surgery
C-section
Other
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Select your social history
Current smoker
Former smoker
Drug or alcohol dependence
None of the above
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Which of these are you dependent on?
Prescription drugs
Alcohol
Street dugs
Other
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Marital Status (over 18 yrs)
Single
Married
Divorced
Separated
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