Community Medical Outreach Vitals Collection Form Home Community Medical Outreach Vitals Outreach Form COMMUNITY MEDICAL OUTREACH VITALS COLLECTION FORMOrganized by: eMedical Comprehensive Consults HospitalPatient InformationFull NameAgeGenderMaleFemalePhone NumberEmail AddressAddressVital Signs AssessmentWeightHeightBMIVisual AcuityBlood Pressure (BP)Heart Rate (Pulse)Respiratory RateTemperatureRandom Blood Glucose (RBG)Medical History (Check all that apply)HypertensionYesNoDiabetesYesNoAsthmaYesNoHeart DiseaseYesNoKidney DiseaseYesNoCholesterolYesNoAllergies (Specify)Other (Specify)Symptoms (Check any that apply)HeadacheYesNoDizzinessYesNoChest PainYesNoShortness of BreathYesNoCough/FeverYesNoWeakness/FatigueYesNoAbdominal PainYesNoOther (Specify)Observations & Notes (For Staff Use Only)Submit
