General Adult Ambulatory Note (SUNY DMC)

Name: [text name="variable_83" default=""]
MRN: [text name="variable_84" default=""]

Chief complaint: [text name="variable_1" default=""]
History of present illness: 
[textarea name="variable_1" default=""]

Review of systems:
General: [textarea name="variable_65" default=" denies fever/chills, fatigue, malaise, weight changes"]
HEENT: [textarea name="variable_66" default=" denies headaches, vision changes, rhinorrhea, sore throat"]
Cardiac: [textarea name="variable_67" default=" denies chest pain, palpitations, peripheral edema"]
Pulmonary: [textarea name="variable_68" default=" denies shortness of breath, dyspnea, cough, sputum production"]
GI: [textarea name="variable_69" default=" denies nausea/vomiting, abdominal pain, diarrhea/constipation, melena/hematochezia"]
GU: [textarea name="variable_70" default=" denies dysuria, hematuria"]
MSK: [textarea name="variable_71" default=" denies myalgias, arthralgias, weakness, numbness/tingling"]
Dermatologic: [textarea name="variable_72" default=" denies rashes"]
Neurologic: [textarea name="variable_73" default=" denies seizures"]
Psychiatric: [textarea name="variable_74" default=" denies depression, anxiety, suicidal ideation, homicidal ideation"]
Endocrine: [textarea name="variable_75" default=" denies polyphagia, polydipsia, polyuria"]
Hematologic/lymphatic: [textarea name="variable_76" default=" denies abnormal bleeding/bruising"]

Past medical history: 
[textarea name="variable_3" default=""]

Past surgical history:
[textarea name="variable_56" default=""]

Allergies: 
[textarea name="variable_4" default=""]

Medications:
[textarea name="variable_5" default=""]

Pharmacy:
[textarea name="variable_57" default=""]

Social history:
Occupation - [text name="variable_41" default=""]
Living situation - [text name="variable_40" default=""]
Social services - [text name="variable_42" default=""]
Tobacco - [text name="variable_6" default=""]
Alcohol - [text name="variable_7" default=""]
Illicit drugs - [text name="variable_8" default=""]

Family history:
[text name="variable_58" default=""]

Vital signs: 
BP – [text name="variable_9" default=""] mm Hg
T - [text name="variable_10" default=""] F
HR - [text name="variable_11" default=""] bpm
RR - [text name="variable_12" default=""] brpm
SaO2 - [text name="variable_13" default=""]%

Physical examination
General: [textarea name="variable_77" default=" AAOx3, NAD"]
HEENT: [textarea name="variable_78" default=" NC/AT, PERRLA, EOMI, mmm, no LAD"]
Cardiovascular: [textarea name="variable_79" default=" RRR, +s1, +s2, no M/R/G"]
Pulmonary: [textarea name="variable_80" default=" CTA b/l, no W/R/R"]
Abdominal: [textarea name="variable_81" default=" soft, NT/ND, no hepatosplenomegaly, +bowel sounds"]
Neurological/MSK/Extremities: [textarea name="variable_82" default=" CN 2-12 intact, normal motor strength, normal sensation, normal reflexes, normal gait "]

Significant laboratory values:
[textarea name="variable_85" default=""]

Radiology:
[textarea name="variable_36" default=""]

Microbiology:
[textarea name="variable_37" default=""]

Assessment & Plan
[textarea name="variable_38" default=""]

RTC: [text name="variable_86" default=""]