Vascular

[text name="variable_1" default="sample text"] year-old 
[checkbox name="variable_2" value="male|female"] with a past medical history of [checkbox name="variable_3" value="HLD|HTN|CAD|T2DM|PAD|CVI|DEMENTIA|CVA|MI|DVT|PE"] presents for [select name="variable_4" value="vascular screening|vein counseling|pad counseling"]. Patient [checkbox name="variable_39" value="admits to limited ambulation| admits to walking frequently at a brisk pace| admits to ambulation, however, at a slow pace| does not ambulate."]
[select name="variable_6" value="admits to|denies to"]
[checkbox name="variable_7" value="Aching|cramping|pain in their arms, buttocks, thighs, or legs when walking|after walking 1 block|after walking several blocks|climbing a flight of stairs|Pain or discomfort in their feet or toes while lying in bed at night"][checkbox name="variable_8" value="painful sores or ulcers on the legs or feet|discolored, pale or bluish arms or legs|numbness, weakness or feeling of heaviness of muscles|cold sensation of the skin of their legs and feet|burning sensation of the feet or toes"]. Patient [textarea name="variable_5" default=""] [select name="variable_9" value="Denies| Admits"] being diagnosed with PAD. Patient is a [checkbox name="variable_10" value="current smoker|former smoker|never smoked"]. Patient is [select name="variable_11" value="compliant with compression stockings|non-compliant with compression stockings|never tried compression stockings|not interested in compression stockings"]. Patient [select name="variable_12" value="is currently taking NSAIDs|is currently not taking any NSAIDs"]. 
[select name="variable_40" value="endorses|denies"] 
family history of 
[checkbox name="variable_1" value="venous disease|malignancy|MI|CVA"]
[checkbox name="variable_43" value="Patient reports having X children|Patient does not have any kids"]

ROS:
[select name="variable_30" value="All 12 ROS negative except for those mentioned above|ROS unchanged since the last visit|General: Denies fatigue, fever, chills, weight loss
HENT: Denies oral sores, neck masses, nasal d/c, hearing problems
Vision: Denies change in vision, eye pain, redness, discharge
Cardiac: As above
Pulmonary: Denies dyspnea, cough
GI: Denies heart burn, swallowing difficulty, abdominal pain, diarrhea, constipation
Neuro: Denies seizure, weakness, numbness
Endo: Denies heat/cold intolerance, weight changes, polyuria, polydipsia
Heme/Onc: Denies unusual bleeding, bruising, clotting
MSK: Denies join pain, swelling, muscle aches
Mental Health: Denies anxiety, depression, mood changes,
Skin/Hair: Denies rashes, non-healing wounds, ulcers, hair loss"]

Meds reviewed and in chart.

Surgical History
[textarea name="variable_37" default="sample text"]

Family History
[textarea name="variable_13" default="Mother Father"]

Allergies
[textarea name="variable_14" default="No Known Drug Allergies"]

Physical Exam
General: 
[checkbox name="variable_15" value="Comfortable, Well-developed, Well-Nourished|Obese|NAD"]
Heart: [checkbox name="variable_16" value="S1S2, RRR, no murmurs, rubs, or gallops"]
Lungs: [checkbox name="variable_18" value="CTABL with no rales, rhonchi, or wheezes."]
Neuro: [checkbox name="variable_20" value="A&Ox3, CN 2-12 GI|A&Ox2|A&Ox1|Peripheral sensation impaired|peripheral sensation intact|Short term memory impaired|Motor: 5/5 all extremities|Motor: Deficit in the RLE|Motor: Deficit in the LLE|Paralyzed in the RLE|Paralyzed in the LLE"]
[text name="variable_17" default="sample text"]
Extremities: 
[checkbox name="variable_21" value="Reticular veins|Telangiectasias|Varicose veins|Corona phlebectatica|Atrophie blanche|Lipodermatosclerosis|1+ Pitting edema|2+ Pitting edema|3+ Pitting edema|4+ pitting edema|Non-pitting edema|Kaposi-stemmer sign +|Kaposi-stemmer sign -"]
Vascular:
[select name="variable_22" value="Carotid 1+ b/l|Carotid 2+ b/l|Carotid 3+ b/l|cannot palpate CAROTID|Carotid 2+ R>L|Carotid 1+ L>R"]
[select name="variable_23" value="Brachial 1+ b/l|Brachial 2+ b/l|Brachial 3+ b/l|cannot palpate BRACHIAL|Brachial 2+ R>L|Brachial 1+ L>R"]
[select name="variable_24" value="Radial 1+ b/l|Radial 2+ b/l|Radial 3+ b/l|cannot palpate RADIAL|Radial 2+ R>L|Radial 1+ L>R"]
[select name="variable_25" value="Popliteal 1+ b/l|Popliteal 2+ b/l|Popliteal 3+ b/l|cannot palpate POPLITEAL|Popliteal 2+ R>L|Popliteal 1+ L>R"]
[select name="variable_26" value="AT 1+ b/l|AT 2+ b/l|AT 3+ b/l|cannot palpate AT|AT 2+ R>L|AT 1+ L>R"]
[select name="variable_27" value="PT 1+ b/l|PT 2+ b/l|PT 3+ b/l|cannot palpate PT|PT 2+ R>L|PT 1+ L>R"]
[checkbox name="variable_28" value="Tissue loss noted B/L|No tissue loss noted of the lower extremities|Dependent Rubor|Livedo Reticularis|Warm extremities B/L|Cold extremities B/L"]
[textarea name="variable_29" default=""]

Assessment:
[text name="variable_1" default="sample text"] year-old 
[text name="variable_2" default="sample text"] with a past medical history of [textarea name="variable_3" default="sample text"] 
[select name="variable_33" value="with a working diagnosis of PAD and CVI|diagnosed with CVI and possible PAD component as evidenced in the above findings|diagnosed with PAD and possible CVI component as evidenced in the above findings"]
[checkbox name="variable_34" value="Diagnosed with CVI|Diagnosed with PAD|Diagnosed with CVI & PAD|Diagnosed with CLI|Diagnosed with ALI"]
[checkbox name="variable_35" value="CEAP 1|CEAP 2|CEAP 3|CEAP 4|CEAP 5|CEAP 6|FONTAINE 1|FONTAINE 2a|FONTAINE 2b|FONTAINE 3|FONTAINE 4"]

Plan:
[text name="variable_36" default="ABI READ and was WNL"]