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Otolaryngology New Patient Questionnaire Mobile App

Have patients complete the Otolaryngology New Patient Questionnaire mobile app prior to seeing the ENT. The app covers areas such as medication list, allergies and adverse reactions, past medical history, past surgical history, family history, social history, and systems review. A GoCanvas account can be specified as being HIPAA compliant. By turning on HIPAA compliance, a number of features that most of users find desirable will be disabled to meet HIPAA Standards. Individual apps in the GoCanvas Application Store can easily be made HIPAA Compliant. If you have any questions or need assistance you can contact our Sales team to help you at Sales@GoCanvas.com. If you would like to enable HIPAA on your GoCanvas account please follow the instructions below: 1. Log onto your Account 2. Click “My Account” in the top right corner of the screen 3. Click “Customize” on the left 4. The third option is for HIPAA Compliance, click “Edit” on the right 5. Check the “Enable HIPAA Compliance” box and select “Save”

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Otolaryngology New Patient Questionnaire Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

  • {{data.title}}

Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico textbox

    NAME:

  • Ico textbox

    MRN:

  • Ico date

    BIRTHDATE:

  • Ico integer

    AGE:

  • Ico date

    Date of Appointment:

  • Ico multiline

    What is the reason for your visit (chief complaint)?

  • Ico multiline

    What is your most recent occupation (if age 18 years or older)?

  • Ico textbox

    Medication Name

  • Ico textbox

    Dose / Frequency (How often taken)

  • Ico dropdown

    Refills Needed?

  • Ico statictext

    Include supplements, herbals and over the counter medications.

  • Ico textbox

    Please indicate any non-medication prescriptions for which you need refills (such as supplies):

  • Ico textbox

    What are you allergic to?

  • Ico multiline

    What happened when you took or used it?

  • Ico statictext

    Please indicate any medications, foods, etc.

  • Ico dropdown

    (Select any medical problems you have had):

  • Ico multiline

    Comments

  • Ico dropdown

    (Select any surgeries you have had and state date of surgery if you know it)

  • Ico multiline

    Comments

  • Ico dropdown

    Select below to report problems your family members have had.

  • Ico textbox

    Mother

  • Ico textbox

    Father

  • Ico textbox

    Sister

  • Ico textbox

    Brother

  • Ico textbox

    Daughter

  • Ico textbox

    Son

  • Ico textbox

    Other (list)

  • Ico dropdown

    ( Select amd social history problems)

  • ...and More!

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