Intake forms

Rooming forms for the clinic, version 3.2 (October 2026). Each form is a PDF: click its name to open or print it. Print at 100% ("Actual size"), not "Fit to page"; the parathyroid forms (N20, F10) have 100 mm lines that staff measure.

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 four sections. Section 1 is for staff and is finished before the visit day. Section 2 starts on its own page and is for the patient. Section 3 is for the medical assistant at rooming. Section 4 is for the physician (chart checks and questionnaire scoring).

Patients can print Section 2 by itself from the Before your appointment page and bring it filled out. If they do, use it in place of the Section 2 pages.

Before the visit (Section 1, staff)

  1. When the visit is scheduled, pick the form (above) and mark the top: New consult, New self-referred or Returning patient, and if returning, New problem or Follow-up problem.

  2. Check each record in Section 1, then check again the business day before the visit.

    • Notes and reports: mark In chart, or request them (write the date) and mark Received when they come.

    • Imaging and hearing tests: write the facility where it was done, then mark the report and the images.

    • OSF: ask OSF to push the images into Carle/Christie Epic and write the date requested.

    • Any other facility, including Fort Jesse: request the report (and images) the day it is found missing.

  3. Items marked "(if done)" are gathered only if they already exist; mark None if there is none. Staff never order tests.

  4. Do the items under "Scheduling and room setup" (when a form has them), such as booking a planned hearing test or setting out supplies.

  5. Anything still missing the business day before goes in the "Still missing" log.

At rooming (Sections 2 and 3)

  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 mark it in Section 3.

  3. The questionnaire is printed in Section 2 in a bordered box. On forms with two questionnaires, the patient fills out only the one that matches their answer to the choice question above them.

  4. In Section 3, record the vitals, add up the questionnaire total (parathyroid forms: measure each mark in millimeters) and write any notes for the doctor.

Physician (Section 4)

Chart checks (medicines, problem list and other chart items) and the scoring guide for each questionnaire.

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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