CASPER, WYOMING
1450 East A Street, Casper, WY 82601
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Mon-Fri: 8AM-4:30PM / Sat-Sun: By Appointment
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(307) 234-8700
serving Wyoming and nearby areas
Clinical Intake
Clinical Intake
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1. Can you confirm what we are we are seeing you for?
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2. How are you feeling? (If any of the following please specify: nausea, vomiting, diarrhea, fevers, chills)
(Required)
3. Do you have any open or surgical wounds?
Yes
No
If a wound is present, where is the wound?
Any redness, swelling, or increased pain to site?
Please send pictures to the following email:
woundcare@rmidcasper.com
4. Are you currently on antibiotics?
Yes
No
If yes, IV or oral?
Name of antibiotic
Any issues with the antibiotics? If so, please explain
5. Any change in your medications since we saw you last?
Yes
No
If yes, what has changed?
6. Any change in health or new diagnosis since we saw you last?
Yes
No
If yes, what has changed?
7. Are you diabetic?
Yes
No
If yes, what does your morning blood sugar usually run?
What was your last A1C?
8. Do you have any concerns you would like to discuss with our provider at your next appointment?
If you haven’t filled out our paperwork please click go to link below.
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