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OrderlyScripts | Musculo Skeletal 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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What is your height?
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What is your weight in pounds
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Health changes

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

Please tell us more about what you are experiencing
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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.

Consent: 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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Purpose of Treatment:

You are seeking treatment for muscle pain, strains, sprains, and/or arthritis. These conditions may cause joint or muscle discomfort, stiffness, swelling, or limited mobility. The goal of treatment is to reduce pain and inflammation, support healing, restore function, and improve your overall quality of life. Management may include medications such as non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, corticosteroids, muscle relaxants, topical agents, or other therapies tailored to your condition.

Potential Benefits:
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  • Relief from muscle or joint pain and stiffness
  • Reduced inflammation and swelling
  • Enhanced healing of strained or sprained muscles
  • Improved physical function and range of motion
  • Better ability to perform daily activities

Potential Risks and Side Effects:

While treatments for muscle and joint conditions are generally safe and effective, they may carry risks and side effects depending on the medication or therapy used. These may include, but are not limited to:
NSAIDs (e.g., ibuprofen, naproxen):
 
  • Stomach upset, ulcers, or gastrointestinal bleeding
  • Increased blood pressure
  • Kidney dysfunction or failure
  • Cardiovascular risks (heart attack or stroke)

Acetaminophen:
 
  • Liver damage (especially at high doses or with alcohol use)

Corticosteroids (oral or injection):
 
  • Increased blood sugar levels
  • Weight gain
  • Bone thinning (osteoporosis) with long-term use
  • Increased risk of infection

Muscle relaxants:
 
  • Drowsiness or dizziness
  • Dry mouth
  • Risk of dependency with prolonged use

Alternatives to Medication:
 
  • Rest, ice, compression, elevation (RICE) for acute strains or sprains
  • Physical therapy or guided rehabilitation
  • Stretching and strengthening exercises
  • Use of assistive devices (e.g., braces, orthotics)
  • Weight management and ergonomic adjustments
  • Referral to a specialist for advanced or interventional therapies

Your Responsibilities:
 
  • Inform your healthcare provider about all current medications and supplements
  • Report any new or worsening symptoms or side effects promptly
  • Follow the prescribed treatment plan, including home care instructions
  • Notify your provider if you are pregnant, breastfeeding, or planning to become pregnant

Consent Statement:

By agreeing to this treatment, you acknowledge that you understand the potential risks and benefits of the medications and therapies recommended for arthritis, muscle strain, or sprain. You may withdraw your consent at any time.

Acknowledgment:

I understand the information provided above and consent to receive treatment for my muscle or joint condition, including the use of medications and therapies discussed.
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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:

• Musculo Skeletal 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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