Triage Form

Let’s take a look at the Sample Triage Form. The top section has information that should be collected by your receptionist during the initial call. This includes:

  • Patient Name​
  • Patient’s Callback Phone Number
  • Today’s Date​
  • Receptionist’s Name or Initials
  • Patient’s Medical Insurance ​(if any)
  • Referral Information (if any)
  • And, the Patient Complaint

​Your receptionist should also have documented the patient’s reported symptoms. ​


Note any bold and capped answers on the sample triage form. These will usually indicate an emergency situation and prompt attention should be given by your team. It’s important that we notify the doctor immediately upon their arrival.


Now it is your responsibility to document and elaborate on reported symptoms. This includes: ​

  • Location: for example, right eye, left eye, or both eyes ​
  • Onset: When did this start?
  • Severity: mild – is it noticeable? moderate – is it bothersome? severe: disruptive/intense​?
  • Timing: is this consistent or are there symptoms that are inconsistent? ​
  • CL wearer: yes, or no? Does the patient wear contacts?​

If your receptionist has collected this information, you may copy this over into your Electronic Medical Record. The History of Present Illness can be useful information to monitor a patient’s progression or regression during and after treatment.​


Treatment may result in the doctor prescribing ointment, drops, or oral medications. It’s important to verify any medication allergies within your Electronic Medical Record, whether the patient is new or established. ​


Due to a reduced workup time, we have to work quickly while still being thorough. Ask the patient if there is any medical history or medications that we should be aware of and document this in the chart. This can usually streamline any pertinent information and get it directly to the doctor. The doctor may provide a more thorough review of medical, social, and family history, depending on diagnosis and treatment plan.


Also, I want to remind you of the importance of documenting accurately. Some cases may be injuries that have resulted from a car or workplace accident. These documents on the chart can end up in a court of law.


Sample Triage Form (PDF)

Sample Triage Form (Excel)