chronic headache pediatric

[text memo="#"] year old [select value="female|male"] here for [text memo="duration"] of  [select value="constant|intermittent"], [select value="stable|worsening|improving"], [checkbox value="throbbing/pulsating|squeezing pressure/tightness |stabbing|pounding|lightning bolts|other: "][text] [checkbox value="unlilateral|bilateral|frontal |parietal|temporal|occipital"] headache. Headaches occur about [text memo="times"] per [text memo="day/week"] and last [text memo="#"] [text memo="minutes/hours/days"]

Headaches [select value="do not|do|sometimes"] wake pt from sleep. [select value="Denies|Endorses"] trouble walking. [select value="Denies|Endorses"] recent trauma. Headaches [select value="are not |are"] worse with cough/defecating/physical activity. [select value="Denies|Endorses"] neck pain. [select value="Denies|Endorses"] back pain. Guardian [select value="denies|endorses"] personality changes. [text memo="(notes)" size="35"]

[checklist value="nausea|vomiting|sensitivity to light|sensitivity to sound|watery or droopy eye|vision changes|cough|congestion|runny nose|fever|dizziness|fainting|muscle weakness"]

Has tried [checkbox value="acetaminophen |ibuprofen|nothing"][text]

Made worse by [textarea default="foods:\nsmells: \nbright lights, noise, lack of sleep, menses (in females), strenuous activity, stress"]
Alleviated by [textarea default="dark, quiet room, cool compress, sleep"]
Unchanged by [textarea memo=""]

Patient estimates about [text memo="#"] hours of sleep per night. [text]
Patient drinks about [text memo="#"] cups of water per day.
[comment memo="children should drink the number of 8 ounce cups of water equal to their age, with a maximum of 64 ounces of water for children over the age of 8"]


MEDs: [text memo="meds" size="50"]
[checklist value="oral contraceptives|glucocorticoids|SSRI/SNRIs|growth hormone|tetracyclines|vitamin A derivatives"]

ALLERGIES: [text memo="allergies" size="50"]
PMH:
[checklist value="sickle cell disease|immune deficiency|cancer or history of cancer |bleeding disorder|heart disease|head trauma|neurofibromatosis|tuberous sclerosis|hydrocephalus or shunt"]
FamHx: 
[checklist name="variable_1" value="migraine|headaches|seizure disorders|neurologic disorders"]
# year old here for duration of , , headache. Headaches occur about times per day/week and last # minutes/hours/days

Headaches wake pt from sleep. trouble walking. recent trauma. Headaches worse with cough/defecating/physical activity. neck pain. back pain. Guardian personality changes. (notes)



Has tried

Made worse by
Alleviated by
Unchanged by

Patient estimates about # hours of sleep per night.
Patient drinks about # cups of water per day.
children should drink the number of 8 ounce cups of water equal to their age, with a maximum of 64 ounces of water for children over the age of 8


MEDs: meds


ALLERGIES: allergies
PMH:

FamHx:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.5, 35 form elements, 64 boilerplate words, 14 text boxes, 3 text areas, 3 checkboxes, 4 check lists, 10 drop downs, 1 comments, 74 total clicks
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