Intake forms

Rooming forms for the clinic, version 1 (October 2026). Each form is a PDF: click its name to open or print it.

How to pick the form

Ask these in order and stop at the first "yes":

  1. Did the patient have surgery for this problem, and is today within that surgery's post-op window? Use the post-op form. Post-op forms are used from the day of surgery through 1 month after (Inspire: until the device is turned on).

  2. Has this clinic seen the patient for this same problem before? Use the follow-up form for that topic. If no topic form fits, use F13 General Follow-up.

  3. Otherwise (new patient, or returning patient with a new problem): use the new-problem form that matches the reason for the visit.

If the visit covers two problems, use one form per problem. If no form on this page fits the visit, use the clinic's current sheet.

Using the forms

Every form has two parts. Section 1 is for staff and is finished before the visit day. Section 2 starts on its own page and is for the patient at rooming.

Before the visit (Section 1, staff)

  1. When the visit is scheduled, pick the form (above) and mark the top: new or returning patient, and if returning, new problem or follow-up problem.

  2. Check each record listed in Section 1, then check again the business day before the visit. For each record, mark where it is and its status:

    • Carle/Christie Epic: in the chart; nothing more to do.

    • OSF: the report is available; ask OSF to push the images into Carle/Christie Epic and log the date requested.

    • Fort Jesse: mark "Login" (the doctor views it there).

    • Any other facility: request the report (and images) the day it is found missing; log who you asked and when.

    • Not done: mark it so nobody looks for it.

  3. Items marked "(if done)" are gathered only if they already exist. Staff never order tests.

  4. Anything still missing the business day before goes in the 1C log.

At rooming (Section 2, patient)

  1. Give the patient the Section 2 pages, or read the questions aloud and write in the answers. Keep the wording as written.

  2. Look at the red-flag box first. If the patient checked Yes to any item, tell the doctor before routine rooming and note the time in the staff box.

  3. If the form names a questionnaire (for example SNOT-22), give the patient that questionnaire too and write its total in the staff box.

  4. Record the vitals listed in the staff box and any notes for the doctor.

New-problem forms

Nose and sinus

Ear and balance

Throat and voice

Head and neck

  • N14 Oral Lesion. A sore, patch or spot in the mouth, with no cancer diagnosis yet. Next visit: F13 (F07 if a biopsy shows cancer).

  • N15 Oral / Throat / Neck Mass. A lump in the mouth, throat, neck or a salivary gland (not on the skin), with no cancer diagnosis yet. Next visit: F13 (F07 if a biopsy shows cancer).

  • N16 Salivary Gland Swelling or Pain. Salivary gland swelling or pain that comes and goes, or salivary stones, without a lasting lump. Next visit: F13.

  • N17 Head and Neck Cancer, New Diagnosis. Biopsy-proven cancer of the mouth, throat, larynx, nasopharynx or a salivary gland. Next visit: F07.

  • N18 Skin Cancer. Skin cancer or a suspicious spot on the skin of the head or neck, including repair of a wound after Mohs surgery. Next visit: F08.

Thyroid and parathyroid

  • N19 Thyroid. Thyroid nodule, goiter, abnormal thyroid scan or biopsy, or overactive thyroid referred for surgery. Next visit: F09.

  • N20 Hyperparathyroidism. High calcium or high parathyroid hormone (PTH). Next visit: F10.

Sleep

Follow-up forms

  • F01 Sinus and Nose Follow-up. Any return visit for a sinus, nasal blockage, smell, nosebleed or nose injury problem, including more than 1 month after sinus or nasal surgery.

  • F02 Ear Follow-up. Return visit for hearing, ringing, ear pain, drainage, fullness or ear tubes (adult or child), including more than 1 month after ear surgery.

  • F03 Dizziness Follow-up. Return visit for dizziness, vertigo or imbalance.

  • F04 Voice Follow-up. Return visit for a voice problem, including more than 1 month after voice box surgery.

  • F05 Swallowing / Globus / Reflux Follow-up. Return visit for swallowing, globus or reflux, including after a swallowing procedure such as dilation.

  • F06 Chronic Cough Follow-up. Return visit for chronic cough.

  • F07 Head and Neck Cancer Follow-up. Any visit during or after treatment for cancer of the mouth, throat, larynx, nasopharynx or a salivary gland, including more than 1 month after cancer surgery.

  • F08 Skin Cancer Follow-up. Return visit for skin cancer of the head or neck, including surveillance and more than 1 month after skin cancer surgery.

  • F09 Thyroid Follow-up. Return visit for thyroid disease, including thyroid cancer surveillance and more than 1 month after thyroid surgery.

  • F10 Parathyroid Follow-up. Return visit for high calcium or parathyroid disease, or mainly for low calcium after neck surgery, including more than 1 month after parathyroid surgery.

  • F11 Snoring / Sleep Apnea Follow-up. Return visit for adult snoring or sleep apnea, including the Inspire turn-on visit and every Inspire visit after it.

  • F12 Pre-op Planning Visit. A visit to plan or consent for a surgery that is already decided. Not for the visit where surgery is first discussed.

  • F13 General Follow-up. Any return visit with no topic follow-up form above, for example tonsils, a child's snoring, a mouth sore, a lump, a salivary gland or facial weakness.

Post-op forms

Use from the day of surgery through 1 month after. After that, use the follow-up form named.

Download all 44 forms (ZIP)

 

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