Tryon Virtual Connect Questionnaire Are you currently physically located in the state of North Carolina?*YesNoDo you have a form of photo identification?*YesNoHave you been seen in the last 12 months by one of our physicians either previously at Mecklenburg Medical Group or at Tryon Medical Partners?*YesNoDo you speak English?*YesNo Is this a medical emergency?*YesNoAre you having chest pain, chest pressure, or chest tightness?*YesNoAre you short of breath?*YesNoAre you having heart palpitations (sensation of heart racing or skipping beats)?*YesNoAre you having abdominal pain?*YesNoAre you having pelvic pain?*YesNoAre you having bleeding?*YesNoAre you having a severe headache?*YesNoIs this a head injury, neck injury, or other trauma?*YesNoAre you seeking medical advice for having passed out or lost consciousness?*YesNoDo you feel like you are going to pass out?*YesNoAre you dizzy, lightheaded, or having vertigo (spinning sensation)?*YesNoAre you having vision changes such as severe eye pain, sensitivity to light, blurred vision, or double vision?*YesNoAre you seeking medical advice for having had a seizure?*YesNoAre you having weakness (loss of strength) anywhere in your body?*YesNoAre you having numbness (lack of feeling) anywhere in your body?*YesNoAre you having a change in mental status, memory loss, or confusion?*YesNoAre you having severe depression, suicidal thoughts, or hallucinations?*YesNoDo you have HIV?*YesNoHave you had an organ transplant?*YesNoAre you on chemotherapy?*YesNoAre you on a medication that suppresses the immune system?*YesNoAre you taking Coumadin or Warfarin?*YesNoIs your reason for this visit to request a pain medication?*YesNoIs your reason for this visit to request a controlled medication that is not a pain medication?*YesNoIs your reason for this visit to complete forms (FMLA, disability, biometric form, handicap placard, etc.)?*YesNoAre you pregnant or breastfeeding?*YesNo
