Tryon Virtual Connect Questionnaire Are you currently physically located in the state of North Carolina?* Yes No Do you have a form of photo identification?* Yes No Have you been seen in the last 12 months by one of our physicians either previously at Mecklenburg Medical Group or at Tryon Medical Partners?* Yes No Do you speak English?* Yes No Is this a medical emergency?* Yes No Are you having chest pain, chest pressure, or chest tightness?* Yes No Are you short of breath?* Yes No Are you having heart palpitations (sensation of heart racing or skipping beats)?* Yes No Are you having abdominal pain?* Yes No Are you having pelvic pain?* Yes No Are you having bleeding?* Yes No Are you having a severe headache?* Yes No Is this a head injury, neck injury, or other trauma?* Yes No Are you seeking medical advice for having passed out or lost consciousness?* Yes No Do you feel like you are going to pass out?* Yes No Are you dizzy, lightheaded, or having vertigo (spinning sensation)?* Yes No Are you having vision changes such as severe eye pain, sensitivity to light, blurred vision, or double vision?* Yes No Are you seeking medical advice for having had a seizure?* Yes No Are you having weakness (loss of strength) anywhere in your body?* Yes No Are you having numbness (lack of feeling) anywhere in your body?* Yes No Are you having a change in mental status, memory loss, or confusion?* Yes No Are you having severe depression, suicidal thoughts, or hallucinations?* Yes No Do you have HIV?* Yes No Have you had an organ transplant?* Yes No Are you on chemotherapy?* Yes No Are you on a medication that suppresses the immune system?* Yes No Are you taking Coumadin or Warfarin?* Yes No Is your reason for this visit to request a pain medication?* Yes No Is your reason for this visit to request a controlled medication that is not a pain medication?* Yes No Is your reason for this visit to complete forms (FMLA, disability, biometric form, handicap placard, etc.)?* Yes No Are you pregnant or breastfeeding?* Yes No
