PATIENT QUESTIONNARIES

Online Patient Questionnaires

In order to save you time and give you more thorough medical care, Dr. Benton is using Instant Medical History (IMH). This secure website allows you to fill out a questionnaire in advance of your appointment, shortening the time it takes to gather the information during your visit. More importantly, it enables you to provide Dr. Benton with information that you think is important for your care.

IMH also allows new patients or patients who have not been seen recently to complete a medical history questionnaire.

The questionnaires are encrypted during transmission across the Internet and are only unencrypted in our office, complying with HIPAA guidelines. The information is then securely stored in both your electronic and paper charts.

Directions

1. Click on the IMH icon.
2. Accept the certificate.
3. Enter the password: mesa
4. Enter your name, date of birth, gender, and patient ID*. (*You MUST enter your patient ID for the questionnaire to work properly. You can get your ID on a previous bill or ask for it when you make an appointment.)
5. Select a reason for your visit from the list or manually list your concern(s). You can list as many concerns as you like, separated by commas or by the word “and.” If you think that two concerns are related to each other, use only the main one. For example if you have a cough and a fever, but you think that the fever might be caused by the cough, enter “cough” as your concern. The questionnaire will ask you about your fever  automatically.
6. Answer the questions as completely as you can. When you have completed the questionnaire, click on “Next” to send it to Dr. Benton. The information will then  securely be transferred to your chart.
7. During your visit, please let Dr. Benton know that you completed the online questionnaire.

List of Common Concerns

• Headache – type in “headache”
• Cough with or without fever, sputum or trouble  breathing – type in “cough”
• Any kind of joint swelling, pain, or difficulty moving joints – type in “joint pain”
• Back pain in any part of the back – type in “back pain”
• Discomfort or burning when you urinate, any trouble urinating, possible urine infection – type in  “difficulty urinating”
• Any problems with your bowel movements – type  in “stools”
•  Ear pain, with or without fever, discharge – type  in “earache”
•  Routine examination – type in “physical exam”
• Trouble sleeping – type in “insomnia”
• Nervous, anxious, unable to focus or concentrate – type in “anxiety”
•  Depressed, down, unable to get going – type  in “depression”
•  Dizzy, lightheaded, trouble with balance – type in “dizzy”
•  Hypertension, high blood pressure – type in “high  blood pressure”
•  Diabetes or concern about possible diabetes – type  in “diabetes”
•  Pediatric well child visits (up to age 10) – type in the child’s age followed by “well child”. For example, “4 month well child” for a 4-month-old follow-up visit.
•  Abdominal gas, bloating, burping, belching – type  in “bloating”
•  Difficulty swallowing food or drinks – type in  “difficulty swallowing”
•  Cold, sore throat, sinus problem – type in “URI”
•  Menstrual period abnormality – type in “periods”