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? MaleFemale 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? * 012345678910 How is your thirst on a scale of 0-10, with 10 being very thirsty? * 012345678910 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? * 012345678910 How is your thirst on a scale of 0-10, with 10 being very thirsty? * 012345678910 What is your blood pressure? What is your pulse oximeter reading? General Daily Information How many times did you void (urinate) today? * 012345678910 How many bowel movements did you have today? * 012345678910 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? * 12345678910 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? * 012345678910 If you are human, leave this field blank. Submit
