Advanced Illness Management Consultation

Date of consult -[date name="date1" default="today"]
Location - [select name="loc" value="Riverside|Enclave"]
Patient Referred by -[text name="variable_1" default="Dr."]

History of Presenting Illness 
[comment memo="write HPI below"]
[textarea name="variable5" default=""]

Allergies -[textarea name="allergies_1" default="No Known Allergies"]
Past Surgical History -[select name="Surgical_1" value="Non Contributory|"][conditional field="Surgical_1" condition="(Surgical_1).is('')"][checkbox name="Surgical_2" value="R Hip replacement|L Hip replacement|R knee replacement|L knee replacement"], [textarea name="Surgery_text" default=""][/conditional]

Family History -[textarea name="family_text" default="Non contributory"]

Social History - [select name="social1" value="This patient denies smoking cigarettes, denies drinking alcohol, denies recreational drug use.|"]
[conditional field="social1" condition="(social1).is('')"][textarea name="socialtxt1" default="This patient reports use of"][/conditional]

Medication - 
[select name="Med1" value="I have reviewed the patients medications|"][conditional field="Med1" condition="(Med1).is('')"][textarea name="Medtxt1" default=""][/conditional]

Review of Systems
[select name="ROS_1" value="This patient is able to provide appropriate answers|This patient is nonverbal/otherwise unable to assess"][conditional field="ROS_1" condition="(ROS_1).is('This patient is able to provide appropriate answers')"]
[comment memo="Default will be negative. Click if positive"]
[checklist name="ROS1" value="Sleep Disturbances|Fatigue|Skin Changes|Recent Falls"]
[checklist name="ROS2" value="Syncope|Headache|Coordination Changes|Weakness| Numbness"]
[checklist name="ROS3" value="Vision Changes|Eye Pain|Nasal Congestion|Nasal Discharge|Hearing Changes|Pain in Ear|Dysphagia|Odynophagia"]
[checklist name="ROS4" value="Chest Pain|Palpitations"]
[checklist name="ROS5" value="Dyspnea|Cough|Shortness of Breath"]
[checklist name="ROS6" value="Nausea|Vomitting|Diarrhea|Constipation|Abdominal Pain"]
[checklist name="ROS7" value="Urinary incontinence|Dysuria"]
[checklist name="ROS8" value="Muscle Weakness|Joint pain|Joint stiffness"] 

Physical Exam [comment memo="Please write in Vitals"]
Vital Signs - [textarea name="VS1" default="BP-  mmgHg T-  °F P-  beats/min R-  breaths/min"]
General - [textarea name="Pe1" default="No acute distress, Well developed, well nourished, Afebrile"]
Neurological  -  [textarea name="Pe2" default="Alert and Oriented, Normal mood and affect, Cranial Nerves II-XII grossly intact"]
HEENT  -  [textarea name="Pe3" default="Head is normocephalic, atraumatic. Bilateral pupils equal and reactive to light and accommodating.  No scleral icterus, no conjunctival pallor.  No neck masses palpated."] 
Pulmonary  -  [textarea name="Pe4" default="Respiratory effort within normal limits. No crackles. No rhales or rhonchi."]  
Cardiovascular  -  [textarea name="Pe5" default="Distal pulses 2+ in all extremeties.  Adequate perfusion. No peripheral signs of cyanosis. Regular rate and rhythm.  No murmurs auscultated."] 
Gastrointestinal  -  [textarea name="Pe6" default="Abdomen soft, nontender, nondistended. No guarding or tenderness. Bowel sounds auscultated."]
Musculoskeletal - [textarea name="Mskphys" default="No difficulty with passive ROS Strength 5/5 bilateral upper extremeties. "]

[textarea name="Ass1" default=""]

[textarea name="Plan1" default=""]
Date of consult -
Location -
Patient Referred by -

History of Presenting Illness
write HPI below

Allergies -

Past Surgical History -

Family History -

Social History -

Medication -

Review of Systems

Physical Exam Please write in Vitals
Vital Signs -

General -

Neurological -


Pulmonary -

Cardiovascular -

Gastrointestinal -

Musculoskeletal -



Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.47, 39 form elements, 52 boilerplate words, 1 text boxes, 16 text areas, 1 dates, 1 checkboxes, 8 check lists, 5 drop downs, 3 comments, 4 conditionals, 59 total clicks
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