pediatric concussion evaluation
[text memo="#"] year old [select value="male|female"] here following a head injury that occurred on [date name="variable_1" default="11/05/2021"]. Patient was injured [textarea memo="mechanism of injury"] Since the injury, patient's symptoms have [select value="improved|deteriorated|stayed about the same"]. [select value="Denies|Endorses"] loss of consciousness Red Flag Symptoms: [checklist value="lethargy/irritability/restlessness|floppiness|abnormal breathing|poor feeding/decrease appetite|neck pain/tenderness|double vision|weakness/tingling in arms/legs|severe/increasing headache|seizure|persistent vomiting"] [select value="denies|endorses"] history of migraine, [select value="denies|endorses"] learning problems, [select value="denies|endorses"]behavioral disorders, [select value="denies|endorses"] history of bleeding disorder, [select value="denies|endorses"] previous neurosurgery, [select value="denies|endorses"] other injuries associated. Concussive Symptoms: [checklist value="disorientation/confusion|blank stare|poor balance/trouble walking|headache|vomiting|memory problems|trouble concentrating/focusing"] (If patient is beyond the acute stage): [checklist value="repeat head trauma|change in mood|change in sleep pattern|symptoms worse with school|symptoms worse with activity "]
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Sandbox Metrics: Structured Data Index 0.87, 15 form elements, 50 boilerplate words, 1 text boxes, 1 text areas, 1 dates, 3 check lists, 9 drop downs, 34 total clicks
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