Patient Progress Report
Patient Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email Address
Have you been tested for covid in the last 10 days?
Yes
No
When was your last Positive covid test?
Have you received the vaccine?
Yes
No
Has your symptoms improved since your last visit?
Yes
No
Do you still have a dry cough?
Yes
No
Do you have any of the following?
Pregnancy
fever or productive cough
Brain Tumor, seizures,
constipation, urinary problems
Have you signed Telehealth consent form?
Yes
No
Upload Picture of Valid ID.
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Are you the only one with access to your email?
Yes
No
Acknowledge that Prescriptions can be sent out 3 days after visit.
Yes
No
Acknowledge that Prescriptions will not be sent out if emails don't match that on file.
Yes
No
Is your signature on file?
Yes
No
Treatment Date
-
Month
-
Day
Year
Date
Progress Notes
Next Treatment Plan
Providers Name: Ughanmwan Efeovbokhan, NP, PhD
Record
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