Complete History Fixed

General Complete History
Case ID # [text name="field_name" default="sample text"]
Date of Service: [text name="field_name" default="sample text"]

Patient Demographics
Age: [text name="field_name" default="sample text"]y.o
Gender: [select name="field_name" value="Male|Female|Other"]
Race: [select name="field_name" value="African American|Caucasian|Hispanic|Asian|Other"]

Clinical Information
Patient Type: [select name="field_name" value="New|Established"]
Time with Patient: [text name="field_name" default="sample text"] mins
Type of Visit: [select name="field_name" value="New|Annual|Interim|Episodic"]

SUBJECTIVE:
Chief complaint (CC): [text name="field_name" default="sample text"]

History of present illness (HPI): 
Patient is a [text name="field_name" default="sample text"] seen for [text name="field_name" default="sample text"]. Patient has a history of [text name="field_name" default="sample text"]

Patient reports[textarea name="field_name" default="sample text"] 

Patient is using [textarea name="field_name" default="sample text"]

Patient has used [textarea name="field_name" default="sample text"]

Before illness: [textarea name="field_name" default="sample text"]

Impact of illness on lifestyle: [textarea name="field_name" default="sample text"]

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PMH: 

General Health and Strength: 
[textarea name="field_name" default="sample text"]

Significant Childhood Illnesses: 
[textarea name="field_name" default="sample text"]

Major Adult Illnesses or Chronic Illnesses: 
[textarea name="field_name" default="sample text"]

Immunizations:
--Influenza: [text name="field_name" default="sample text"]
--PCV13:[text name="field_name" default="sample text"]
--PPSV23:[text name="field_name" default="sample text"]
--Tdap or Td:[text name="field_name" default="sample text"]
--MMR:[text name="field_name" default="sample text"]
--VAR:[text name="field_name" default="sample text"]
--RZV or ZVL:[text name="field_name" default="sample text"]
--HAV:[text name="field_name" default="sample text"]
--HBV:[text name="field_name" default="sample text"]

Limitation of abilities: 
--Hearing: [checklist name="field_name" value="Unilateral|Bilateral|sensory loss|neural loss|sensorineural loss|wears hearing aid"]

--Vision: [checklist name="field_name" value="legally blind|glasses|contacts"]
--Speech:[text name="field_name" default="sample text"]

--Gait:[checklist name="field_name" value="frequent falls|cane|tripod cane|quad-cane|walker|wheeled walker|frequent falls|rollator|wheelchair|electric wheelchair"]

--Dexterity:[textarea name="field_name" default="sample text"]

--Swallow: [textarea name="field_name" default="chopped|ground|soft|pureed|nectar thick liquid|honey thick liquid"|full dentures|upper dentures|lower dentures|partials|caps"]


--Exposure to TB: [text name="field_name" default="sample text"] 
--Last PPD:[text name="field_name" default="sample text"]
--Other Possible exposures: [text name="field_name" default="sample text"]
--Self-care:[text name="field_name" default="sample text"]
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Medications:
[textarea name="field_name" default="sample text"]

Allergies/ADR: 
[textarea name="field_name" default="Name/Reaction"]
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Past surgical history (PSH): 
[textarea name="field_name" default="Date, Dx, Hospital, Complications"]
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Social history
--Place of birth/childhood: [text name="field_name" default="sample text"] 
--Socioeconomic status: [text name="field_name" default="sample text"] 
--Education level: [text name="field_name" default="sample text"] 
--Places visited: [text name="field_name" default="sample text"]
--Places lived: [text name="field_name" default="sample text"]
--Diet: [text name="field_name" default="sample text"]
--Exercise: [text name="field_name" default="sample text"]
--Home Conditions: [text name="field_name" default="sample text"]
--Occupations: [text name="field_name" default="sample text"]
--Environment: [text name="field_name" default="sample text"]
--Military Record: [text name="field_name" default="sample text"]
--Religious or Cultural Preferences: [text name="field_name" default="sample text"]
--Access to Care: [text name="field_name" default="sample text"]
--Smoking History: [text name="field_name" default="sample text"]
--Alcohol Use: [text name="field_name" default="sample text"]
--Illicit Drugs: [text name="field_name" default="sample text"]
--Sexual History: [text name="field_name" default="sample text"]
--Breast Self-Exams: [text name="field_name" default="sample text"]
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Family history: 
--Mother: [text name="field_name" default="sample text"]
--Father: [text name="field_name" default="sample text"]
--Siblings: [text name="field_name" default="sample text"]
--Children: [text name="field_name" default="sample text"]
--Grandparents:[text name="field_name" default="sample text"]
--Aunts or Uncles: [text name="field_name" default="sample text"]
--Cousins: [text name="field_name" default="sample text"]
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Risks:
[textarea name="field_name" default="sample text"]
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Review of Systems: 

--Constitutional: c/o [checklist name="field_name" value="fatigue|fever|chills|malaise|generalized weakness|diffuse pain|sleeping problems|night sweats|weight changes"] [text name="field_name" default="sample text"]. Denies: [checklist name="field_name" value="fatigue|fever|chills|malaise|generalized weakness|diffuse pain|sleeping problems|night sweats|weight changes"].

--Head: c/o [checklist name="field_name" value="headaches|dizziness|syncope|dizziness|sinus pain|LOC"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="headaches|dizziness|syncope|dizziness|sinus pain|LOC"].

--Eyes: c/o [checklist name="field_name" value="vision loss|blurriness|blind spots|floaters|diplopia|photophobia|eye pain|halos|erythemia|drainage|change in appearance|dryness"].[text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="vision loss|blurriness|blind spots|floaters|diplopia|photophobia|eye pain|halos|erythemia|drainage|change in appearance|dryness"].

--Ears: c/o [checklist name="field_name" value="ear pain|tinnitus|hearing loss|fullness in ears|drainage|drainage|vertigo|frequent infections"] [text name="field_name" default="sample text"]. [checklist name="field_name" value="ear pain|tinnitus|hearing loss|fullness in ears|drainage|drainage|vertigo|frequent infections"].

--Nose: c/o [checklist name="field_name" value="loss of smell|obstruction|epistaxis|drainage|congestion|tenderness|sinus pain|lesions"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="loss of smell|obstruction|epistaxis|drainage|congestion|tenderness|sinus pain|lesions"].

--Mouth and Throat: c/o [checklist name="field_name" value="hoarseness|change in voice B|sore throat|bleeding in mouth|hemoptysis|swollen gums|recent abscess |recent extractions|soreness in mouth|soreness in tongue|ulcers|change in taste"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="hoarseness|change in voice|sore throat|bleeding in mouth|hemoptysis|swollen gums|recent abscess |recent extractions|soreness in mouth|soreness in tongue|ulcers|change in taste"]. 

--Neck: c/o [checklist name="field_name" value="neck pain|stiffness|edema"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="neck pain|stiffness|edema"] [text name="field_name" default="sample text"].

--Cardiac: c/o [checklist name="field_name" value="chest pain|dyspnea| orthopnea|edema|palpitations|shortness of breath with activities|loss of consciousness|paroxysmal nocturnal dyspnea|need to elevate head at night due to SOB"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="chest pain|dyspnea| orthopnea|edema|palpitations|shortness of breath with activities|loss of consciousness|paroxysmal nocturnal dyspnea|need to elevate head at night due to SOB"].

--Vascular: c/o [checklist name="field_name" value="claudication|color changes in extremities|parathesias|coldness in extremities|tendency to bruise"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="claudication|color changes in extremities|parathesias|coldness in extremities"].

--Respiratory: c/o [checklist name="field_name" value="Pain with Respiration|Dyspnea|Cyanosis|Coughing|Wheezing|Sputum|Hemoptysis|Night Sweats|shortness of breath|exercise intolerance with activity"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="Pain with Respiration|Dyspnea|Cyanosis|Coughing|Wheezing|Sputum|Hemoptysis|Night Sweats|shortness of breath|exercise intolerance with activity"].

--Gastrointestinal: c/o [checklist name="field_name" value="appetite changes|heartburn|dysphagia|abdominal pain|nausea|vomiting|diarrhea|constipation|change in stools|flatulence|anorexia|hematemesis |intolerance to foods|painful bowel movements|bloating|cramping|anorexia|bright red blood per rectum|foul smelling dark black tarry stools|tenesmus"] [text name="field_name" default="sample text"]. Denies[checklist name="field_name" value="appetite changes|heartburn|dysphagia|abdominal pain|nausea|vomiting|diarrhea|constipation|change in stools|flatulence|anorexia|hematemesis |intolerance to foods|painful bowel movements|bloating|cramping|anorexia|bright red blood per rectum|foul smelling dark black tarry stools|tenesmus"] 

--Endocrine: c/o [checklist name="field_name" value="thyroid tenderness|thyroid enlargement|excessive thirst|excessive hunger/excessive urination|heat intolerance|cold intolerance|unexplained Weight changes|changes in face or body hair|striae|increased hat or glove size|mood swings|sweaty|diarrhea|oligomenorrhoea|tremor, palpitations|visual disturbances|feeling slow|feeling tired|depression thin hair| croaky voice|heavy periods|constipation|dry skin|orthostatic symptoms, darkening of skin in non-sun exposed places"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="thyroid tenderness|thyroid enlargement|excessive thirst|excessive hunger/excessive urination|heat intolerance|cold intolerance|unexplained Weight changes|changes in face or body hair|striae|increased hat or glove size|mood swings|sweaty|diarrhea|oligomenorrhoea|tremor, palpitations|visual disturbances|feeling slow|feeling tired|depression thin hair| croaky voice|heavy periods|constipation|dry skin|orthostatic symptoms, darkening of skin in non-sun exposed places"].

--Hematological/Lymphatic: c/o [checklist name="field_name" value="anemia|purpura|petechia| prolonged or excessive bleeding after dental extraction/injury|bruising|blood clots|enlarged lymph nodes|tender lymph nodes"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="anemia|purpura|petechia| prolonged or excessive bleeding after dental extraction/injury|bruising|blood clots|enlarged lymph nodes|tender lymph nodes"].

--Genitourinary: c/o [checklist name="field_name" value="dysuria|urinary frequency|urinary urgency| hematuria|flank pain|suprapubic pain|nocturia|polyuria|dark or discolored Urine|hesitancy|terminal dribbling|loss of force of stream|loss or urine with laughing, coughing, sneezing, exercise, position changes|loss of sensation|loss of control"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="dysuria|urinary frequency|urinary urgency| hematuria|flank pain|suprapubic pain|nocturia|polyuria|dark or discolored Urine|hesitancy|terminal dribbling|loss of force of stream|loss or urine with laughing, coughing, sneezing, exercise, position changes|loss of sensation|loss of control"]

Reproductive (female): c/o [checklist name="field_name" value="change in cycle duration and frequency|vaginal bleeding irregularities|vaginal discharge|vaginal pain|menstrual pain|changes in sexual arousal or libido|infertility|painful intercourse"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="change in cycle duration and frequency|vaginal bleeding irregularities|vaginal discharge|vaginal pain|menstrual pain|changes in sexual arousal or libido|infertility|painful intercourse"]. Gravida [text name="field_name" default="sample text"] Para [text name="field_name" default="sample text"] Abortus [text name="field_name" default="sample text"]. LMP: [text name="field_name" default="sample text"].

Reproductive (male): c/o [checklist name="field_name" value="difficulty with erection|difficulty with sexual arousal|lack of stamina|difficulty with emissions|testicular pain"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="difficulty with erection|difficulty with sexual arousal|lack of stamina|difficulty with emissions|testicular pain"].

--Musculoskeletal: c/o [checklist name="field_name" value="joint pain or tenderness|joint swelling|muscles pain|ROM changes|stiffness |bony deformity|misalignment"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="joint pain or tenderness|joint swelling|muscles pain|ROM changes|stiffness |bony deformity|misalignment"].

--Integument:
c/o [checklist name="field_name" value="pruritis|rashes|stria|lesions|wounds|pigmentation changes|acanthosis nigricans|nodules|lumps/bumps|excessive dryness|discoloration|texture changes|eruptions"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="pruritis|rashes|stria|lesions|wounds|pigmentation changes|acanthosis nigricans|nodules|lumps/bumps|excessive dryness|discoloration|texture changes|eruptions"].

--Neurological: c/o [checklist name="field_name" value="change in sight|changes in smell|change in hearing|changes in taste|change in sensation|faints|fits|funny turns|headache|paraesthesias|numbness|paralysis|limb weakness|poor balance|loss of coordination|speech problems|seizures|dizziness|headaches|tremors|memory loss"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="change in sight|changes in smell|change in hearing|changes in taste|change in sensation|faints|fits|funny turns|headache|paraesthesias|numbness|paralysis|limb weakness|poor balance|loss of coordination|speech problems|seizures|dizziness|headaches|tremors|memory loss"].

--Psychiatric: c/o [checklist name="field_name" value="depression|change in sleep patterns|anxiety|difficulty concentrating|difficulty paying attention|change in body image|changes in work and school performance|paranoia|anhedonia|lack of energy|episodes of mania|episodic change in personality|sexual or financial binges|irritability|tension|suicidal thoughts|homicidal thoughts"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="depression|change in sleep patterns|anxiety|difficulty concentrating|difficulty paying attention|change in body image|changes in work and school performance|paranoia|anhedonia|lack of energy|episodes of mania|episodic change in personality|sexual or financial binges|irritability|tension|suicidal thoughts|homicidal thoughts"]

--Breasts: c/o [checklist name="field_name" value="breast pain/soreness|discharge|lumps"]
[text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="breast pain/soreness|discharge|lumps"]
==============================================
OBJECTIVE:
PE:
--Vital signs: T[text name="field_name" default="sample text"] P[text name="field_name" default="sample text"] R[text name="field_name" default="sample text"] BP[text name="field_name" default="sample text"] O2 Sat [text name="field_name" default="sample text"] on [text name="field_name" default="sample text"]

--General Appearance: 
LOC:[checklist name="field_name" value="Alert|Awake|Aware|Asleep|Responds to Verbal Stimulus|Responds to Pain|Unresponsive |Lethargic|Unconscious"]
Gait: [text name="field_name" default="sample text"] 
Hygiene and Grooming:[text name="field_name" default="sample text"]
Affect:[text name="field_name" default="sample text"]
Nutrition: [checklist name="field_name" value="well-nourished|cachexic"]
Distress: [checklist name="field_name" value="observable pain cues|appears in no acute distress"]

--HEENT: 
HEAD: Saw on insepction: [checkbox name="field_name" value="NC/AT"] [text name="field_name" default="sample text"].
EYES: Saw on inspection: [checklist name="field_name" value="PERRLA|EOMI|anticeteric|Injection|No injection|Papilledema|No papilledema|Cornea clear|cornea cloudy"], Fundus: [text name="field_name" default="sample text"], Eyebrows:[text name="field_name" default="sample text"] eyelids: [text name="field_name" default="sample text"] sclera: [text name="field_name" default="sample text"], Conjuctiva: [text name="field_name" default="sample text"]. Felt on Palpation: [text name="field_name" default="sample text"]. Snellen: [text name="field_name" default="sample text"]. Jaeger Chart: [text name="field_name" default="sample text"]. Ichihara Chart: [text name="field_name" default="sample text"]
EARS: Saw on inspection: [checklist name="field_name" value="discharge|no discharge|inflammation|no inflammation|TM intact|TM not intact|TM bulging|TM Concave|TM Gray|TM Discolored|TM cloudy|Visible bony structures"]. Felt On Palpation: [text name="field_name" default="sample text"]. Weber Test: [text name="field_name" default="sample text"]. Rinne Test: 
Nose: Saw on inspection: [checklist name="field_name" value="Nares red|nose symmetric|nose assymetric|Nares patent|Nares not patent|Mucous membranes moist and pink| mucous membranes moist and red|mucous membranes moist and grey|polyps present|no septal defect|septal defect"] [text name="field_name" default="sample text"], discharge: [text name="field_name" default="sample text"]. Felt on palpation: Frontal Sinuses: [text name="field_name" default="sample text"] Maxillary Sinuses: [text name="field_name" default="sample text"], Trans-illumination: [text name="field_name" default="sample text"], [text name="field_name" default="sample text"]
Mouth/Throat: Saw on inspection: Lips:
[text name="field_name" default="sample text"], Dental Caries: [text name="field_name" default="sample text"], Alignment: [text name="field_name" default="sample text"], Oropharynx: [text name="field_name" default="sample text"], Uvula: [text name="field_name" default="sample text"], Tonsils: [text name="field_name" default="sample text"], Tongue: [text name="field_name" default="sample text"], Gag Reflex: [select name="field_name" value="present|not present"]. [text name="field_name" default="sample text"]

--NECK: Saw on inspection [checklist name="field_name" value="Visible goiter|No visible Goiter|Edema|Discoloration"] [text name="field_name" default="sample text"], Felt on palpation: [checklist name="field_name" value="thrill|no thrill|LAD|No LAD|Neck supple|Neck rigid"] [text name="field_name" default="sample text"]. Lymph nodes: Aneterior Cervical: [text name="field_name" default="sample text"]. Posterior Cervical:[text name="field_name" default="sample text"]
Tosillar: [text name="field_name" default="sample text"] Sub-mandibular: [text name="field_name" default="sample text"]
Sub-Mental: [text name="field_name" default="sample text"] Supraclavicular: [text name="field_name" default="sample text"]. Heard on Auscultation: Bruit|No Bruit"] [text name="field_name" default="sample text"]

--RESPIRATORY: 
[textarea name="field_name" default="LUNGS: symmetric expansion/accessory muscle use/no accessory muscle use/barrel chest/Clear to auscultation and percussion/dimished breath sounds/areas of consolidation/without rales/with rales/without rhonchi/with rhonchi/audible wheeze/no wheezing/audible stridor/clubbing/no clubbing"] 
Cyanosis: [text name="field_name" default="sample text"]

--CARDIOVASCULAR:
[checkbox value="S1/S2, no S3/S4|soft S1, normal S2, no S3/S4|S1/S2, S3 present, no S4|S1/S2, no S3, S4 present|no murmur|holosystolic murmur|midsystolic murmur|late systolic murmur|diastolic murmur|loudness 1/6|loudness 2/6|loudness 3/6|loudness 4/6|loudness 5/6|loudness 6/6|rhythm is regular|rhythm is irregular|rhythm is irregularly irregular"][checkbox name="pulses" value="Peripheral pulses are 2+ throughout|Peripheral pulses are diminished|Peripheral pulses exam - "][conditional field="pulses" condition="(pulses).is('Peripheral pulses exam - ')"][text][/conditional][checkbox name="carotids" value="No carotid bruits|Carotid bruits on the left|Carotid bruits on the right|Bilateral Carotid bruits|Carotid pulses exam - "][conditional field="carotids" condition="(carotids).is('Carotid pulses exam - ')"][text][/conditional]. JVP: [text name="field_name" default="sample text"], Heaves/Lifts: [text name="field_name" default="sample text"] PMI:[text name="field_name" default="sample text"], [text name="field_name" default="sample text"], 

--MUSCULOSKELETAL:
--JOINTS: 
[textarea name="field_name" default="sample text"]
[textarea default="Neck: Range of motion with normal flexion, extension, right rotation, and left rotation. There is no palpable paraspinal muscle spasm."]
[textarea default="Upper extremity muscle strength is normal bilaterally. Sensation is normal bilaterally. Reflexes: normal and symmetric at biceps, triceps, brachioradialis"]
[textarea default="C spine x-ray: normal, without loss of cervical lordosis, no degenerative changes"][/conditional][conditional field="Q1" condition="(Q1).is('Back Pain')"]
[textarea default="General Appearance: No distress. Patient able to ambulate well. Gait is not antalgic."]
[textarea default="Straight leg raising negative bilaterally for radicular symptoms."]
[textarea default="Sensory exam in the legs is normal. "]
[textarea default="Knee reflexes are normal and symmetric."]
[textarea default="Ankle reflexes are normal and symmetric"]
[textarea default="Strength is normal and symmetric."]
[textarea default="No paraspinal muscle spasm. There is no midline tenderness. ROM of spine with normal flexion, extension, lateral range of motion to the right and left, and rotation to the right and left."][/conditional][conditional field="Q1" condition="(Q1).is('Shoulder Pain')"]
[textarea default="General Appearance: no acute distress"]
[textarea default="Neck: Range of motion with normal flexion, extension, right rotation, and left rotation. There is no palpable paraspinal muscle spasm."]
[textarea default="Shoulder: Symmetrical bilaterally, FROM flex/ex/IR/ER/abduction/adduction, No erythema or edema, Nontender to palpation, Negative: Hawkins, Neers, Yergusons, Speeds, empty can, 5/5 strength biceps/triceps/grip, Radial pulse full. Cap refill <2 seconds, Sensory intact to light touch distally."][/conditional][conditional field="Q1" condition="(Q1).is('Knee Pain')"]
[textarea default="General Appearance: no acute distress
[textarea default="Knee: Normal joint contours. No effusion. Normal range of motion. Normal strength on extension and flexion against resistance. No joint line pain medially or laterally. McMurray negative for crepitus and pain medially and laterally. There is no swelling or pain over the pes anserine bursa. Collateral ligament testing shows no laxity or pain. Anterior drawer test and Lachman shows no anterior cruciate laxity. Posterior drawer negative for laxity as well. No popliteal mass or palpable tenderness."][/conditional]

--GASTROINTESTINAL:
[conditional field="short" condition="(short).is('')"][textarea cols=80 rows=5 default="ABDOMEN: soft, flat, nontender without masses or hepatosplenomegaly. Bowel sounds active. No bruits."][/conditional][checkbox memo="Long Version" name="long" value=""][conditional field="long" condition="(long).is('')"][textarea cols=80 rows=5 default="ABDOMEN: ***obese/soft/flat/rigid/distended/tympany to percussion/hepatomegaly/splenomegaly/RUQ scar/midline scar/RLQ scar/suprapubic scar/right flank scar/left flank scar***
"]
[textarea cols=80 rows=5 default="***bowel sounds active/decreased bowel sounds/increased bowel sounds/no bruits/abdominal bruit at ---/right femoral artery bruit/left femoral artery bruit/bilateral femoral bruits***"]
[textarea cols=80 rows=5 default="***no guarding/no rebound tenderness/no abdominal tenderness to palpation/suprapubic tenderness/diffuse tenderness/tender to palpation at ---/RLQ tenderness/rebound tenderness/diminished bowel sounds/hyperactive bowel sounds/guarding/Rovsing's positive/mass at ---/hernia at ---***"][/conditional]

--GENITOURINARY:
[textarea name="field_name" default="Bladder distended/bladder nondistended, Bladder firm/Bladder soft/no tenderness/suprapubic tenderness/rash to perineum/urethral meatus patent/circumcised/not circumcised/rugae present/rugae absent/moist pink vulva/uterine prolapse present/stage I/stage II/stage III/rectal prolapse present/anal wink present/anal wink absent/BCR present/BCR absent/rectal tone present/gaping anus/rectal tone impaired/stool in rectal vault/no stool in rectal vault/rectal mass present"]. Prostate: [text name="field_name" default="sample text"] 
PVR: [text name="field_name" default="sample text"]. [text name="field_name" default="sample text"]

--INTEGUMENTARY:
[textarea name="field_name" default="skin warm/skin cool/skin hot/flushing/diaphoretic/poor skin turgor/good skin turgor/dry skin/xerosis/friable/pale/yellow/petechiae/purpura"].
Wounds: 
[textarea name="field_name" default="sample text"]
Rashes: 
[textarea name="field_name" default="sample text"]
Scars:
[textarea name="field_name" default="sample text"]

--NEUROLOGIC: 
Gait: [select name="G1" value="steady coordinated gait|abnormal"][conditional field="G1" condition="(G1).is('abnormal')"][checkbox value="an unsteady uncoordinated gait|a slow unsteady gait|walks on heels and toes with out problems|has difficulty with walking"][/conditional] [text]
Rhomberg: [select value="negative|postive"] [text]
Rapid alternating movements: [select value="normal|abnormal"] [text]
Cranial nerves: [select value="II-XII intact|abnormal"] [text]
cranial nerves II-XII intact.
Sensation: [select value="intact and symmetric at upper and lower extremities bilaterally|abnormal"] [text]
Strength: [select value="intact and symmetric at upper and lower extremities bilaterally|abnormal"] [text]
Reflexes:
[checkbox memo="Right Biceps" name="RB" value=""][conditional field="RB" condition="(RB).is('')"]Right Biceps: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Left Biceps" name="LB" value=""][conditional field="LB" condition="(LB).is('')"]Left Biceps: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Right Triceps" name="RT" value=""][conditional field="RT" condition="(RT).is('')"]Right Triceps: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Left Triceps" name="LT" value=""][conditional field="LT" condition="(LT).is('')"]Left Triceps: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Right Forearm" name="RF" value=""][conditional field="RF" condition="(RF).is('')"]Right Forearm: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Left Forearm" name="LF" value=""][conditional field="LF" condition="(LF).is('')"]Left Forearm: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Right Patella" name="RP" value=""][conditional field="RP" condition="(RP).is('')"]Right Patella: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Left Patella" name="LP" value=""][conditional field="LP" condition="(LP).is('')"]Left Patella: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Right Ankle" name="RA" value=""][conditional field="RA" condition="(RA).is('')"]Right Ankle: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Left Ankle" name="LA" value=""][conditional field="LA" condition="(LA).is('')"]Left Ankle: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional]
Babinski: [select value="negative|postive"] [text]
The following other neurologic findings were found: [textarea default="none"]

--BREAST:
[text size=80 default="No chest deformity, asymmetry. Normal contours. No nodules, masses, tenderness, or axillary adenopathy. No nipple discharge."][comment memo="Enter abnormal details below..."]
[select value="|Left side:|Right side:"] [checkbox value="dimpling|mastectomy|fibrocystic changes|breast tenderness|muscle tenderness|dominant mass|nipple discharge|axillary adenopathy"] [text]
[select value="|Left side:|Right side:"] [checkbox value="dimpling|mastectomy|fibrocystic changes|breast tenderness|muscle tenderness|dominant mass|nipple discharge|axillary adenopathy"] [text]

--PSYCH: [textarea name="field_name" default="sample text"]
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ASSESSMENT:
--VS:
[textarea name="field_name" default="sample text"]

Nurtition: Weight: [text name="field_name" default="sample text"] BMI: [text name="field_name" default="sample text"] Weight changes: [text name="field_name" default="sample text"]

--Pertinent lab values: 
[textarea name="field_name" default="sample text"]
--Pertinent diagnostic test results: 
[textarea name="field_name" default="sample text"]

--Mammogram: [text name="field_name" default="sample text"]

--Last Pap Smear: [text name="field_name" default="sample text"]

Actual diagnosis:
[text name="field_name" default="sample text"]
DDx:
[textarea name="field_name" default="sample text"]
==============================================
PLAN: 
--On this visit: 
Procedures: 
[textarea name="field_name" default="sample text"], 
Purpose of Procedure: 
[textarea name="field_name" default="sample text"], 
Consent was [select name="field_name" value="obtained verbally|obtained written|not obtained"]

--Medications Discontinued:
[textarea name="field_name" default="sample text"]

--Medications Given: 
[textarea name="field_name" default="sample text"]

--Medication Refills:
[textarea name="field_name" default="sample text"]

--Medication Samples:
[textarea name="field_name" default="sample text"]

--Labs Ordered:
[textarea name="field_name" default="sample text"]

--Diagnostics Ordered:
[textarea name="field_name" default="sample text"]

--Referrals:
[textarea name="field_name" default="sample text"]

--Follow-up:
[textarea name="field_name" default="sample text"]

--Education Given:
[textarea name="field_name" default="sample text"]