Palpitations
Onset [text] prior to evaluation
Onset while: [text]

Discomfort (0=none, 10=severe)
Location: [text]
Radiation: [text]
Severity now (0-10): [text]
Severity at worst (0-10): [text]
Duration: [text]
Frequency: [text]
Characterized as: [text].

Modifiers
Relieved with [text]
Worse with [text]
[text] exertional

Key Symptoms
[select value="no|YES"] <-- rapid heart beat
[select value="no|YES"] <-- slow heart beat
[select value="no|YES"] <-- irregular heart beat

Associated Symptoms
[select value="no|YES"] <-- Complete Loss of Consciousness
[select value="no|YES"] <-- Near loss of consciousness
[select value="no|YES"] <-- chest pain
[select value="no|YES"] <-- shortness of breath
[select value="no|YES"] <-- hyperventilation (lip numbness, hand paresthesias)
[select value="no|YES"] <-- Falls

Exposures
[select value="no|YES"] <-- Low blood sugar
[select value="no|YES"] <-- Excessive alcohol
[select value="no|YES"] <-- Drug abuse
[select value="no|YES"] <-- Caffeine

Pertinent ROS
[select value="no|YES"] <-- fever
[select value="no|YES"] <-- dizziness
[select value="no|YES"] <-- cough
[select value="no|YES"] <-- nausea/vomiting
[select value="no|YES"] <-- abdominal pain
[select value="no|YES"] <-- abnormal bleeding (menorrhagia, gastrointestinal)
[select value="no|YES"] <-- unilateral leg swelling
[select value="no|YES"] <-- recent prolonged travel, recent trauma, hypercoagulable state, hormonal therapy

Pertinent PMH:
[select value="no|YES"] <-- Arrhythmia
[select value="no|YES"] <-- Pacemaker
[select value="no|YES"] <-- Valve Disorder
[select value="no|YES"] <-- Coronary Artery Disease
[select value="no|YES"] <-- Thyroid disease
[select value="no|YES"] <-- Diabetes Mellitus
[select value="no|YES"] <-- Anxiety disorder
[select value="no|YES"] <-- COPD
[checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"]
reference:
contributed by Dr. Scott Moses, creator/author of the Family Practice Notebook
[link url="//www.fpnotebook.com" memo="fpnotebook.com"]
[/conditional]

Palpitations
Onset prior to evaluation
Onset while:

Discomfort (0=none, 10=severe)
Location:
Radiation:
Severity now (0-10):
Severity at worst (0-10):
Duration:
Frequency:
Characterized as: .

Modifiers
Relieved with
Worse with
exertional

Key Symptoms
<-- rapid heart beat
<-- slow heart beat
<-- irregular heart beat

Associated Symptoms
<-- Complete Loss of Consciousness
<-- Near loss of consciousness
<-- chest pain
<-- shortness of breath
<-- hyperventilation (lip numbness, hand paresthesias)
<-- Falls

Exposures
<-- Low blood sugar
<-- Excessive alcohol
<-- Drug abuse
<-- Caffeine

Pertinent ROS
<-- fever
<-- dizziness
<-- cough
<-- nausea/vomiting
<-- abdominal pain
<-- abnormal bleeding (menorrhagia, gastrointestinal)
<-- unilateral leg swelling
<-- recent prolonged travel, recent trauma, hypercoagulable state, hormonal therapy

Pertinent PMH:
<-- Arrhythmia
<-- Pacemaker
<-- Valve Disorder
<-- Coronary Artery Disease
<-- Thyroid disease
<-- Diabetes Mellitus
<-- Anxiety disorder
<-- COPD
display/hide references

Result - Copy and paste this output: