Explain your symptoms or tell us how we can help today.*

Do you have allergies to any medications?*

Yes
No

If yes, please list any medications you have allergies to:

Are you pregnant or breastfeeding?*

Yes
No

Unfortunately we cannot proceed with your request based on the information you have provided.

Have you been exposed to someone with flu or flu symptoms?*

Yes
No

Do you use an inhaler?*

Yes
No

What symptoms have you been experiencing recently?*

Please best explain the description of fever or chills:*

Feeling warm no measured temperature
Measured temperature of 100.8 degrees (fahrenheit) or higher
Severe uncontrollable chills (teeth chattering)

Unfortunately we cannot proceed with your request based on the information you have provided.

Please explain your cough:*

Dry
Productive with clear phlegm
Productive with yellow or green phlegm
Productive with bloody phlegm

Please explain your nasal drainage:*

Yellow or green nasal drainage
Watery nasal drainage
Nasal bleeding

Please explain your ear drainage:*

Yellow or green ear drainage
Watery ear drainage
Ear bleeding

If you've listed "other", please explain your symptoms:*

How Long have you been having these symptoms?*

Started today
1-3 days
4-7 days
Over 1 week

Have you ever been treated for acute bronchitis?*

Yes
No

How long ago?*

What medications were you treated with?*

Zpak (Azithromycin)
Cefitin (Cefuroxime)
Doxycycline
Levaquin

Did treatment work?*

Yes
No

Would you prefer the same treatment?*

Yes
No
Leave to doctor’s discretion

Smoker?*

Yes
No
Never

Alcohol use?*

Any medical family history?*

Yes
No

Please explain your medical family history:*

Do you have any medical conditions?*

Yes
No

Please explain your medical conditions:*

Have you ever had any surgeries or recent hospitalizations?*

Yes
No

Please explain your surgeries or recent hospitalizations:*

Do you currently take any medications, herbals, or supplements?*

Yes
No

Please list any medications, herbals, or supplements:*

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