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Anti-nausea Follow-up Questionaire
To ensure your provider can safely evaluate your symptoms, we’ll ask a few questions about your health history, medications, and allergies.
Please identify all your current medical conditions
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Please list all your current medications including dosages.
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Please list all of your known allergies.
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Medical background​​​​​​​

Have there been any health or medication changes, ED visits or hospitalizations since your last check-in?
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Medical background​​​​​​​

Please tell us more about the changes in your health
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Current medication

How are you doing on the current medication?
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Current medication

Please tell us more about what you are experiencing
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Side effects

Have you experienced any side effects from the current medication?
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Side effects

Please tell us more about the side effects you are experiencing
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Current treatment

Would you like to continue your current treatment, change the dose, or change the medication?
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What other information or questions do you have for the doctor?
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Please attest to the following confirming that all information you have provided to us is true and complete.

I verify that I am the patient and that I have answered the questions asked in this intake form.  I confirm that I have reviewed and understood all the questions asked of me.  I attest that the answers and information I have provided in this questionnaire is true and complete to the best of my knowledge. I understand that it is critical to my health to share complete health information with my doctor.  I will not hold the doctor or affiliated medical practice responsible for any oversights or omissions, whether intentional or not, in the information that I provided

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You have reported experiencing nausea and/or vomiting, conditions that can significantly affect your comfort, daily activities, and overall quality of life. Ondansetron (Zofran) is a medication commonly prescribed to help prevent or relieve these symptoms by blocking certain chemical receptors in the body responsible for inducing nausea and vomiting.

The use of ondansetron may:
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  • Reduce or prevent episodes of nausea and vomiting
  • Improve comfort and quality of life
  • Help you maintain proper nutrition and hydration

While ondansetron is generally well-tolerated, possible side effects may include:
 
  • Headache
  • Constipation
  • Dizziness or lightheadedness
  • Fatigue or drowsiness
  • Dry mouth
  • Rare but serious side effects such as changes in heart rhythm (including QT prolongation) or severe allergic reactions (rash, itching, swelling)

You may need to avoid ondansetron or use it with caution if you:
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  • Have a known heart rhythm disorder, such as congenital long QT syndrome
  • Are currently taking other medications that can affect the heart’s rhythm or serotonin levels
  • Have a history of severe allergic reactions to ondansetron or similar medications

Alternative treatment options for nausea and vomiting include:
 
  • Dietary modifications (small, frequent meals; avoiding triggers)
  • Ginger (such as ginger tea or candies)
  • Acupressure or acupuncture
  • Other prescription or over-the-counter anti-nausea medications
  • Behavioral techniques (relaxation exercises, controlled breathing)

I understand the potential benefits, risks, and possible side effects of using ondansetron. I have been informed about alternative treatment options. I agree to inform my healthcare provider of any side effects or adverse reactions I may experience. I understand that this consent is voluntary and that I can withdraw from treatment at any time.

By selecting below, I consent to the use of ondansetron for the treatment of my nausea and/or vomiting.
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Based on the information you provided, this visit type requires in-person medical evaluation for safe and appropriate care.

What you were seeking help for:

Anti-nausea Follow-up

Why this happens

Some symptoms, medical history details, or risk factors mean a condition can’t be safely managed through telemedicine. A licensed provider must examine you in person to ensure the right diagnosis and treatment.
Please visit a local urgent care, primary care clinic, or emergency department if your symptoms worsen.

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