Palpitations History

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:

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