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HISTORY:
[checkbox name="historian" value="provided by patient||SO/family member present during visit|chaperon/MA present during visit||interpretation provided by family member/SO|interpretation provided by MA||complete history unobtainable d/t poor effort/affect|complete history unobtainable d/t cognitive changes or lack of knowledge|complete history unobtainable d/t language skills|"][textarea cols=70 rows=1]
RECENT HISTORY:
[checkbox name="recent" value="non-contributory||visit to ER/UC|hospitalization/surgery/procedure|new medications|antibiotic use|diagnostic study|"][textarea cols=70 rows=1]
MEDICATIONS:
[checkbox name="medications" value="none|Rx|OTC||taking as prescribed|not taking as prescribed||reports no side effects|reports side effects||effective|partially effective|not effective||demonstrates knowledge of medications/reasons/dosages taken|unable to name medications/reasons/dosages taken||medication list/labels/containers available for review|medication list/labels/containers not available for review||insulin/BS log available for review|insulin/BS log not available for review"][textarea cols=70 rows=1]
PMSH:
[checkbox name="pmh" value="reviewed|non-contributory|"][textarea cols=70 rows=1]
HPI:
[checkbox name="new_chronic" value="new problem|chronic condition|acute exacerbation of chronic condition"]
Duration: [textarea cols=70 rows=1]
[checkbox name="duration" value="hours|days|weeks|months|years"]
Symptoms:
[checkbox name="sx" value="increasing in severity|persisting|decreasing in severity|occasional|"][textarea cols=70 rows=1]


REVIEW OF SYSTEMS: [+] reported [-] not reported
negative except as stated in HPI

CONSTITUTIONAL: [textarea cols=70 rows=1]
[checklist name="constitutional_symptoms" value="fever|chills|body aches|malaise|fatigue|night sweats|hot flashes|unintentional wt loss"]
HEAD/FACE: [textarea cols=70 rows=1]
[checklist name="head_symptoms" value="headache|scalp swelling|trauma|facial pain|facial swelling|facial drooping|facial numbness"]
EYES: [textarea cols=70 rows=1]
[checklist name="eye_symptoms" value="decrease in vision|scotoma|floaters|blurriness|photophobia|halos|dryness|redness/irritation|watery|discharge|lid swelling|lid nodule|periorbital swelling|trauma|pain with EOM"]
EARS: [textarea cols=70 rows=1]
[checklist name="ear_symptoms" value="pain|pressure|discharge|bleeding|wax|possible FB|hearing loss|ringing"]
NOSE: [textarea cols=70 rows=1]
[checklist name="nose_symptoms" value="discharge|PND|congestion|sinus pressure|snoring|bleeding|possible FB|trauma"]
MOUTH: [textarea cols=70 rows=1]
[checklist name="mouth_symptoms" value="sores|dryness|tongue pain/swelling|toothache|infection/swelling|jaw pain/clicking|changes in taste"]
THROAT: [textarea cols=70 rows=1]
[checklist name="throat_symptoms" value="sore throat|odynophagia|dysphagia|hoarseness|globus"]
NECK: [textarea cols=70 rows=1]
[checklist name="neck_symptoms" value="pain|stiffness|swelling|swollen glands"]
CV: [textarea cols=70 rows=1]
[checklist name="cv_symptoms" value="chest pain/pressure|SOB|palpitations|lightheadedness|fainting|exertional dyspnea|orthopnea|rapid wt gain|ankle swelling|ankle discoloration|varicose veins|leg cramps"]
CHEST/RESPIRATORY: [textarea cols=70 rows=1]
[checklist name="chest_symptoms" value="cough|phlegm|wheezing|pain w/ breathing|rib pain|breast swelling/lump"]
GI: [textarea cols=70 rows=1]
[checklist name="gi_symptoms" value="poor appetite|nausea|vomiting|abdominal pain|constipation|diarrhea"]
GU: [textarea cols=70 rows=1]
[checklist name="gu_symptoms" value="dysuria|burning|frequency|urgency|hematuria|hesitancy|retention"]
[checkbox memo="GYN" name="notes2" value=" "][conditional field="notes2" condition="(notes2).is(' ')"][checklist name="gyn_symptoms" value="abnormal bleeding|missed period|irregular periods|heavy and/or prolonged periods|passing clots|spotting|dyspareunia"][/conditional]
MSK: [textarea cols=70 rows=1]
[checklist name="msk_symptoms" value="myalgias|neck pain|back pain|shoulder pain|hip pain|knee pain|chronic pain/meds|joint pain/deformity|localized muscle/soft tissue pain/swelling"]
NEURO: [textarea cols=70 rows=1]
[checklist name="neuro_symptoms" value="dizziness|vertigo|poor balance|abnormality of walk|focal weakness|blackouts|speech difficulty|tremor|seizures|urinary/bowel changes|tingling/numbness"]
PSYCH: [textarea cols=70 rows=1]
[checklist name="psych_symptoms" value="irritability|confusion|withdrawal|depression|apathy|anxiety|mood swings|memory loss|insomnia"]
ENDO: [textarea cols=70 rows=1]
[checklist name="endo_symptoms" value="cold intolerance|skin dryness|hair loss|polyuria"]
LYMPH/HEMA: [textarea cols=70 rows=1]
[checklist name="hem_symptoms" value="gland swelling|bruising|anticoagulation|DVT/clotting|anemia"]
ALLERGIES/IMMUNE: [textarea cols=70 rows=1]
[checklist name="allergy_symptoms" value="atopy|food allergies|autoimmune dz|h/o cancer"]
DERM: [textarea cols=70 rows=1]
[checklist name="derm_symptoms" value="dryness|pruritus|rash|hives|redness|swelling|wounds"]




Ambulation/DME:
[checkbox name="ambulation" value="no ambulation aids/DME|ambulation requires walker|ambulation requires cane|ambulation requires wheelchair||wearing cervical collar|wearing lumbar support|wearing extremity brace|"][textarea cols=70 rows=1]

Appearance:
[checkbox name="appearance" value="well-appearing|no signs of discomfort visible while sitting in chair|no signs of discomfort visible while ambulating & getting on/off exam table||normal built|heavy built|emaciated|frail||ill-appearing|tired-looking|short of breath|diaphoretic||good hygiene|disheveled|bizarre clothes|body odor||drowsy|appears impaired|slumped|"][textarea cols=70 rows=1]

Head/Face:
[checkbox name="head" value="normocephalic, atraumatic|normal hair distribution|symmetrical face|CN grossly intact||plethoric face|alopecia|facial droop|"][textarea cols=70 rows=1]

Eyes:
[checkbox name="eyes" value="clear conjunctiva w/o exudates or hemorrhage, anicteric sclera, EOM intact without nystagmus|visual acuity grossly intact|cornea(s) clear||glasses|contacts|conjunctival injection|epiphora|conjunctival exudate|allergic shiners|dysconjugate gaze|"][textarea cols=70 rows=1]

Ears:
[checkbox name="ears" value="symmetrical & intact auricles bilaterally|hearing to conversation intact|clear canals without erythema or discharge|TMs normal in appearance|"][textarea cols=70 rows=1]

Nose:
[checkbox name="nose" value="nares patent bilaterally|septum midline|no facial tenderness|mucosa pink & moist||swollen & boggy mucosa|mucosal congestion|clear discharge|yellow discharge|crusty discharge|rhinophyma|"][textarea cols=70 rows=1]

Mouth:
[checkbox name="mouth" value="tongue normal in appearance w/o lesions and with good symmetrical movements|moist oral mucosa without lesions||upper denture|lower denture||poor dentition|oral ulcers|gum swelling|tooth decay|"][textarea cols=70 rows=1]

Throat:
[checkbox name="throat" value="normal voice|patent pharynx w/o swelling or exudates|uvula midline|clear pharynx w/o exudates||hoarseness|vesicles on soft palate|petechiae on soft palate|pharyngeal erythema w/o exudates|"][textarea cols=70 rows=1]

Neck:
[checkbox name="neck" value="symmetric with free painless ROM and no masses|supple|no LAD|no bruit or JVD||anterior LAD|posterior LAD||thyroid enlargement|nuchal tenderness|"][textarea cols=70 rows=1]

Chest/Lungs:
[checkbox name="lungs" value="normal work of breathing, symmetrical chest expansion, no stridor|clear and equal breath sounds bilaterally||chest wall atraumatic and non-tender|no axillary or supraclavicular LAD||SOB|decreased bilaterally|wheezing|crackles|"][textarea cols=70 rows=1]

CV:
[checkbox name="cv" value="regular rhythm|no murmurs|no ankle edema|pedal skin warm with good & equal pulses||tachycardia|irregular heart rhythm|systolic murmur||calf tenderness|ankle edema|varicosities|stasis discoloration|"][textarea cols=70 rows=1]

Abdomen:
[checkbox name="abd" value="not examined||normal visual inspection, no distension|normal active bowel sounds|soft non-tender|no bruit auscultated over AA and renal arteries||protruding|surgical scar|umbilical hernia|diffuse tenderness over entire abdomen w/o RRG|hypoactive bowel sounds|hyperactive bowel sounds|direct non-rebound tenderness|colostomy in situ|"][textarea cols=70 rows=1]

GU:
[checkbox name="gu" value="not examined||no suprapubic tenderness|no CVAT bilaterally||Foley in situ|normal external genitalia|no inguinal LAD||testicular tenderness|urethral discharge|verrucous papules|vesicles|crusted lesions|"][textarea cols=70 rows=1]

MSK:
[checkbox name="spine" value="no gross deformities, moves all extremities with good ROM for age|full weight-bearing|normal curvature & ROM in C- & L-spine for patient’s age||non-tender C-spine with good ROM|non-tender L-spine with good ROM||strength, tone, & bulk symmetrical & grossly intact||kyphosis|paraspinal muscle spasm|C-spine tenderness & DROM|neck pain with active motion|paracervical muscle spasm|old surgical scar(s) in C-spine|trapezius tenderness||L-spine tenderness|reduced painful ROM in lumbar region|paraspinal muscle spasm|trigger points in L-spine|old surgical scar(s) in L-spine||heel-walk & toe-walk without difficulty|negative seated SLR|positive seated SLR|"][textarea cols=70 rows=1]

Neuro:
[checkbox name="neuro" value="normal concentration and attention|memory grossly intact||balance & coordination grossly intact|normal speech|no gross motor deficits||sensation symmetrical & grossly intact|extremities strong w/o atrophy, tremor or fasciculations|reflexes normoactive||antalgic gait|wide gait|shuffling gait|diffuse numbness w/o dermatomal pattern|dystonia|"][textarea cols=70 rows=1]

Skin:
[checkbox name="skin" value="grossly intact, no rashes|no bruises|normal turgor||tattoos|body piercings|poor turgor|dry|sweaty|"][textarea cols=70 rows=1]

Behavior:
[checkbox name="behavior" value="calm|pleasant|respectful||cooperative with exam||exam limited by urgency|exam limited by poor cooperation|exam limited by safety concerns||guarded|anxious|fearful|suspicious|hypervigilant||irritable|frustrated|restless||labile|sighing|crying||agitated|raising voice||defensive|argumentative|hostile||forceful|intense|euphoric||demanding particular medication, test, referral, or accommodation||withdrawn|indifferent|appears to be responding to internal psychotic process|"][textarea cols=70 rows=1]

Psychomotor Activity:
[checkbox name="psychomotor" value="no involuntary movements||tremor|tardive dyskinesia|tics||bradykinetic|fidgeting|picking skin|twirling hair|cracking knuckles||threatening posture/movement|grimacing, furrowing eyebrows|tightening jaw|breathing hard||shaking extremities|clenching fists|intense staring||standing up and/or pacing|opening door to hallway|exited exam room during exam|"][textarea cols=70 rows=1]

Speech:
[checkbox name="speech" value="clear & coherent|normal rate & rhythm||slurred|monotonous|stuttering||hypoverbal|hyperverbal||loud|soft||slow|rapid|pressured||repetitive questions|cursing, swearing|criticisms of staff|verbal threats|"][textarea cols=70 rows=1]

Thought Process:
[checkbox name="thought_process" value="organized/linear/logical||circumstantial|tangential|perseveration|flight of ideas|preoccupation with illness|catastrophization|overgeneralization|unrealistic beliefs|negativism|pessimism|blaming others|staff splitting|delusions|paranoid ideation|"][textarea cols=70 rows=1]

OFFICE DIAGNOSTICS:
[checkbox name="office_diag" value="normal|non-specific changes|no acute findings|discussed with patient/SO|official report to follow|"][textarea cols=70 rows=1]

A/P:
[textarea cols=80 rows=8]

RX:
[checkbox name="order_RX" value="none|OTC||electronic|paper|given to MA to be transmitted to pharmacy|"][textarea cols=70 rows=1]

LABS:
[checkbox name="order_lab" value="none||CBC|CMP|TSH|A1C|Lipids|PSA|FOBT/FIT|UA||HIV, RPR, HCV, GC, CT|UDS|"][textarea cols=70 rows=1]

IMAGING:
[checkbox name="order_imaging" value="none||X-ray|US|MRI|"][textarea cols=70 rows=1]

REVIEWED:
[checkbox name="reviewed" value="MA notes|med list|medication containers|previous visits|PMP|laboratory/diagnostic studies|specialty reports|hospital discharge|"][textarea cols=70 rows=1]

INSTRUCTED ON:
[checkbox name="instructions" value="vital signs/exam findings/recommendations|report medication side effects to clinic immediately|appropriate follow up||laboratory/diagnostic studies|specialty consults||smoking cessation|weight loss/diet/exercise|importance of controlling chronic conditions|age-appropriate screening and immunization|"][textarea cols=70 rows=1]

BARRIERS TO CARE:
[checkbox name="barriers" value="none identified during visit||poor cooperation with exam|lack of motivation|negative attitude to diagnostic impression & proposed tx|failed to obtain old records|failed to complete referrals or testing|failed to bring medications for med review|poor compliance with medication regimen||incomplete history|vague shifting complaints|history not supported by objective findings||multiple comorbidities|recent hospitalization||polypharmacy|lack of interest in nonpharmacologic therapies|overwhelming focus on Rx drugs|medication use in response to environmental stress|intolerance of multiple meds|overreliance on short-acting meds||multiple office contacts|frequent ER/UC visits||altered mental status|hostile/disruptive behavior|active psychiatric diagnosis|alcohol or substance use|social/cultural barriers|victim of abuse|"][textarea cols=70 rows=1]

DISPOSITION:
[checkbox name="disposition" value="RTC as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx||RTC 24 hours|RTC 2-3 days|RTC 1 week||referred to ER for immediate treatment via 911|referred to ER for immediate treatment via private transport|declined emergency transfer|left clinic before being discharged|asked to leave clinic|"][textarea cols=70 rows=1]

TOTAL TIME:
[checkbox name="time" value="15 minutes or less|15-30 minutes|30-45 minutes|visit dominated by counseling|"][textarea cols=70 rows=1]
HISTORY:

RECENT HISTORY:

MEDICATIONS:

PMSH:

HPI:

Duration:

Symptoms:



REVIEW OF SYSTEMS: [+] reported [-] not reported
negative except as stated in HPI

CONSTITUTIONAL:

HEAD/FACE:

EYES:

EARS:

NOSE:

MOUTH:

THROAT:

NECK:

CV:

CHEST/RESPIRATORY:

GI:

GU:

GYN
MSK:

NEURO:

PSYCH:

ENDO:

LYMPH/HEMA:

ALLERGIES/IMMUNE:

DERM:





Ambulation/DME:


Appearance:


Head/Face:


Eyes:


Ears:


Nose:


Mouth:


Throat:


Neck:


Chest/Lungs:


CV:


Abdomen:


GU:


MSK:


Neuro:


Skin:


Behavior:


Psychomotor Activity:


Speech:


Thought Process:


OFFICE DIAGNOSTICS:


A/P:


RX:


LABS:


IMAGING:


REVIEWED:


INSTRUCTED ON:


BARRIERS TO CARE:


DISPOSITION:


TOTAL TIME:

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