Telehealth Pre-Screening Appointment
Fill out the following to receive a call back for a telehealth appointment
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Today's Date *
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Legal Name *
Preferred Name *
Pronouns *
Born with *
Date of Birth *
Age *
Status *
John Jay Email *
Phone Number *
Address *
EMPLID # *
Do you have health insurance? *
What brings you to the Wellness Center today? *
Is this a new problem or have you had this in the past? *
When did the current issue start? *
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What are the symptoms? Describe what you are experiencing. *
What have you done to treat it? What worked and what didn't work? *
How can we help you? What is the best outcome? *
Are you in pain now? *
If you answered yes, rate your pain 1-10
mild
severe
Clear selection
Current Medications (including birth control, vitamins, and over-the-counter meds): *
ALLERGIES *
If you answered yes, list allergies
Height *
Weight *
LMP (For those with ovaries, what was the first day of your last menstrual period?)
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Past Medical History (check all that apply) *
Required
Have you traveled internationally within the past 3 months? *
If yes, where?
Do you use nicotine? *
If yes, check all that apply
How often do you drink alcohol? *
Do you participate in sexual activity? *
If yes, with who?
Clear selection
What form of birth control do you use?
How do you prevent sexually transmitted infections? *
Do you feel safe at home? *
Availability *
Required
Preferred time:
This consent provides the medical staff at John Jay College permission to perform reasonable and necessary medical examinations, testing, and treatment on me. It is my responsibility to provide accurate and complete information about all matters pertaining to my health, including medications and past or present medical problems. I am responsible for following the instructions and advice of my healthcare providers and responsible for the consequences of disregarding instructions or medical advice. I am responsible for reporting changes in my condition or symptoms and it is also my responsibility to notify my healthcare provider if I do not understand information about my care and/or treatment. I have the right to discuss the treatment plan and ask questions regarding the purpose, potential risks, and benefits of any intervention and test ordered for me. I have the right to refuse treatment and to be informed of the possible consequences of the refusal. *
Required
Consultation and most medical care by the Nurse Practitioner at John Jay College is free to students. However, there is a fee for some special treatments and testing. Fees for these in-house services will be discussed and payment collected at the time of service. It is my responsibility to pay third-party laboratory services and diagnostic testing facilities directly. I am responsible for all charges (in-house or third-party) whether covered by health insurance or not. It is my responsibility to learn what my insurance covers. *
Required
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