Add Patient

A. Date of Visit?

B. Age of patient in years?

C. Type of Visit? Choose one. [Well Child Check (WCC), Follow-Up Visit (FUV), New Patient Visit (NPV), Consult (CON)]

D. Sex of patient assigned at birth? [Male (M) or Female (F)]

E. Gender identity of patient? Choose one. [Male (M), Female (F), Transmale (TM), Transfemale (TF), Non-binary (NB), Didn't ask (DA)]

F. Was medication prescribed at the initial visit? [Yes (Y) or No (N)]

G. Was the follow-up visit completed within 30 days of the initial visit? [Yes (Y) or No (N)]

H. What was the result of the follow-up visit? Choose one. [Change Medication (CM), Change Dosage (CD), Keep prescription the same (KS), or Discontinue Medication (DM)]

I. Were the rating tool results documented in the medical record? [Yes (Y) or No (N)]

J. Do you have additional patients to enter? [Yes (Y) or No (N)]