Pediatrics
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Date: [date name="variable_1" default="11/18/2018"]

IDENTIFYING DATA

Initials:[text name="initials" default=" "]
Informant:[text name="informant" default=" "]
Reliability of Informant: [text name="reliability" default=" "]
PCP:[text name="pcp" default=" "]
Referring Physician:[text name="referred" default=" "]

CHIEF COMPLAINT:

[text name="CC" default=" "]

HPI:

[textarea name="hpi" default=" "]

ROS:

General:[checkbox name="rosgeneral" value="Change in weight|Change in activity|Fever"][text name="rosgentext" default=" "]
HEENT:[checkbox name="rosheent" value="Change in vision|Change hearing|sore throat|runny nose|epistaxis|bilateral ear pain|eye discharge/redness"][text name="rosheenttext" default=" "]
Respiratory:[checkbox name="rosresp" value="cough|wheezing|SOB|dyspnea|snoring"][text name="rosresptext" default=" "]
Cardiovascular:[checkbox name="roscards" value="cyanosis|fatigability|syncopy"][text name="roscardstext" default=" "]
Gastrointestinal:[checkbox name="rosgi" value="Feeding difficulties|reflux|diarrhea|constipation|vomiting|abdominal pain"][text name="rosgitext" default=" "]
Genitourinary:[checkbox name="rosgu" value="hematuria|dysuria|frequency|urgency|leakage|enuresis|menstrual irregularities"][text name="rosgutext" default=" "]
Endocrine:[checkbox name="rosendo" value="polyuria|polydipsia|cold intolerance"][text name="rosendotext" default=" "]
Neurological:[checkbox name="rosneuro" value="convulsions|tic|tremors|gait abnormality|headache"][text name="rosneurotext" default=" "]
Musculoskeletal:[checkbox name="rosmsk" value="muscle pain|weakness|limp|arthralgia"][text name="rosmsktext" default=" "]
Dermatologic:[checkbox name="rosderm" value="rashes|bruising|petechiae|change in hair/nails|color changes"][text name="rosdermtext" default=" "]
Psychological:[checkbox name="rospsych" value="depression|anxiety|SI|HI"][text name="rospsychtext" default=" "]

PMHx:

Pregnancy:[text name="pmhpreg" default=" "][comment memo="Maternal Age;GsPs;Prenatal Care;maternal health;HIV;STD;GBS;meds;drugs/EtOH"]
Perinatal:[text name="pmhperi" default=" "][comment memo="gest age;birth weight;vag or C-Section;intrapartum Abx?"]
Neonatal:[text name="pmhneo" default=" "][comment memo="length to DC;hypoglycemia;jaundice;card screening;hearing screening;rashes;fevers"]
Feeding Hx:[text name="pmhfeed" default=" "][comment memo="breast/formula;formula type;diet;picky?"]
Growth & Development:[text name="pmhgnd" default=" "][comment memo="milestones met?;growth/dev problems?;age of potty training;sexuak dev(including menarche)"]
Illnesses/Problems:[text name="pmhill" default=" "][comment memo="Chronic/Non-Chronic with dates"]
Accidents/Injuries:[text name="pmhacc" default=" "][comment memo="Dates;nature;complications"]
Hospitalizations:[text name="pmhhosp" default=" "][comment memo="Dates;nature;complications"]

SURGICAL Hx:

[text name="surghx" default=" "][comment memo="Dates;nature;complications"]

FAMILY Hx:[comment memo="mom;dad;sibling;grandparents"]

[textarea name="famhx" default=" "]

SOCIAL Hx:[comment memo="School;Home;hobby;sport;sleep;behavior issues;HEEADSSS"]
[textarea name="shx" default=" "]

IMMUNIZATIONS:[comment memo="up to date?;alt schedule?;detailed report preffered"]

[text name="immuno" default=" "]

CURRENT MEDICATIONS:[comment memo="name, dose, frequency, reason"]

[textarea name="crntmeds" default=" "]

ALLERGIES:[comment memo="include reaction"]

[text name="allrgs" default=" "]
Date:

IDENTIFYING DATA

Initials:
Informant:
Reliability of Informant:
PCP:
Referring Physician:

CHIEF COMPLAINT:



HPI:



ROS:

General:
HEENT:
Respiratory:
Cardiovascular:
Gastrointestinal:
Genitourinary:
Endocrine:
Neurological:
Musculoskeletal:
Dermatologic:
Psychological:

PMHx:

Pregnancy:Maternal Age;GsPs;Prenatal Care;maternal health;HIV;STD;GBS;meds;drugs/EtOH
Perinatal:gest age;birth weight;vag or C-Section;intrapartum Abx?
Neonatal:length to DC;hypoglycemia;jaundice;card screening;hearing screening;rashes;fevers
Feeding Hx:breast/formula;formula type;diet;picky?
Growth & Development:milestones met?;growth/dev problems?;age of potty training;sexuak dev(including menarche)
Illnesses/Problems:Chronic/Non-Chronic with dates
Accidents/Injuries:Dates;nature;complications
Hospitalizations:Dates;nature;complications

SURGICAL Hx:

Dates;nature;complications

FAMILY Hx:mom;dad;sibling;grandparents



SOCIAL Hx:School;Home;hobby;sport;sleep;behavior issues;HEEADSSS


IMMUNIZATIONS:up to date?;alt schedule?;detailed report preffered



CURRENT MEDICATIONS:name, dose, frequency, reason



ALLERGIES:include reaction

Result - Copy and paste this output: