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approximately 21 views since there was any semblance of structure or societal order in a Walmart parking lot.
[checkbox name="historian" value=" new patient|existing patient||parent present|sibling/another family member present|social services/group home/foster family present|chaperon/MA present during visit||interpretation provided by family member/SO|interpretation provided by MA|"][textarea cols=50 rows=3]

CONCERNS/QUESTIONS:
[checkbox name="cc" value="no concerns reported||consider formal screening and/or evaluation|"][textarea cols=50 rows=3]

SPECIAL NEEDS:
[checkbox name="special" value="none|"][textarea cols=50 rows=2]

INTERVAL HISTORY:
[checkbox name="interval" value="sick contact|travel|ER/UC visit|hospitalization/surgery/procedure|diagnostic/laboratory studies|specialty consults|new/changed medications|ABX use|"][textarea cols=50 rows=3]

MEDICATIONS:
[checkbox name="medications" value="none reported||Rx|OTC|"][textarea cols=50 rows=2]

PMH:
reviewed
[checkbox name="pmh" value="frequent infections|asthma|allergies|weight issues|"][textarea cols=50 rows=3]

GROWTH/DEVELOPMENT/ANTICIPATORY GUIDANCE -
discussed and/or handout provided:
[checkbox name="development" value="no concerns raised||normal BMI|high BMI|low BMI|"][textarea cols=50 rows=2]

VACCINATION:
[checkbox name="preventative" value="UTD|missing shots||administered today|deferred|declined|"][textarea cols=50 rows=2]

SCREENING - age-specific questionnaire provided & discussed:
[checkbox name="screen" value="depression|tobacco, alcohol, and drug use||no concers|abnormal||referral submitted|declined referral|"][textarea cols=50 rows=3]

SCHOOL - discussed and/or handout provided:
[checkbox name="schoool" value="no concerns raised||IEP/504/behavior plan||parental/teacher concerns regarding behavioral issues|parental/teacher concerns regarding performance|"][textarea cols=50 rows=2]

NUTRITION - discussed and/or handout provided:
[checkbox name="nutrition" value="reports adequate daily intake of fruits and vegetables|reports inadequate daily intake of iron|reports inadequate daily intake of calcium||no concerns raised|"][textarea cols=50 rows=2]

DENTAL - discussed and/or handout provided:
[checkbox name="dental" value="brushing twice daily, flossing|reports dental home|reports no dental home||no concerns raised||dental referral submitted|"][textarea cols=50 rows=2]

INTERPERSONAL - discussed and/or handout provided:
[checkbox name="interpers" value="relationships with family, peers, and community|concern & respect for others, compassion and empathy|interpersonal violence||no concerns raised|"][textarea cols=50 rows=2]

MENTAL HEALTH - discussed and/or handout provided:
[checkbox name="mental" value="body image|mood|sleep||no concerns raised|referral submitted|"][textarea cols=50 rows=2]

PHYSICAL ACTIVITY - discussed and/or handout provided:
[checkbox name="physical" value="daily exercise|screen time|behaviors that optimize wellness and contribute to a healthy lifestyle||no concerns raised|"][textarea cols=50 rows=2]

SAFETY - discussed and/or handout provided:
[checkbox name="safety" value="seat belt and helmet use|driving and substance use|acoustic trauma|sun protection|firearm safety||firearms at home|no concerns raised|"][textarea cols=50 rows=2]

TOBACCO, ALCOHOL, DRUGS - discussed and/or handout provided:
[checkbox name="drug" value="Tobacco, e-cigarettes, alcohol, prescription drugs, street drugs||denies use|reports social use|smoking household||declined to discuss|no concerns raised|"][textarea cols=50 rows=2]

SEXUAL - discussed and/or handout provided:
[checkbox name="sex" value="sexual orientation|gender identityue||safe sex|pregnancy and sexually transmitted infections||not sexually active|sexually active||declined to discuss|no concerns raised|"][textarea cols=50 rows=2]



ROS
10-point review of systems was performed and results were negative except for any positive results below

Constitutional:
[checklist name="constitutional_symptoms" value="fever|chills|body aches|malaise|fatigue|wt gain"][textarea cols=50 rows=2]
Head/face:
[checklist name="head_symptoms" value="headache|facial pain|facial swelling"][textarea cols=50 rows=2]
Eyes:
[checklist name="eye_symptoms" value="decrease in vision|scotoma|floaters|redness/irritation|discharge|lid swelling|periorbital swelling|trauma|pain with EOM"][textarea cols=50 rows=2]
Ears:
[checklist name="ear_symptoms" value="pain|pressure|discharge|wax"][textarea cols=50 rows=2]
Nose:
[checklist name="nose_symptoms" value="discharge|PND|congestion|sinus pressure|snoring|bleeding"][textarea cols=50 rows=2]
Mouth:
[checklist name="mouth_symptoms" value="sores|dryness|tongue pain/swelling|toothache|infection/swelling|jaw pain/clicking|changes in taste"][textarea cols=50 rows=2]
Throat:
[checklist name="throat_symptoms" value="sore throat|odynophagia|dysphagia|hoarseness|globus"][textarea cols=50 rows=2]
Neck:
[checklist name="neck_symptoms" value="pain|stiffness|swelling|swollen glands"][textarea cols=50 rows=2]
CV:
[checklist name="cv_symptoms" value="chest pain/pressure|SOB|palpitations|lightheadedness|fainting"][textarea cols=50 rows=2]
Chest/Respiratory:
[checklist name="chest_symptoms" value="cough|phlegm|wheezing|pain w/ breathing|rib pain|breast swelling/lump"][textarea cols=50 rows=2]
GI:
[checklist name="gi_symptoms" value="poor appetite|nausea|vomiting|abdominal pain|constipation|diarrhea"][textarea cols=50 rows=2]
GU:
[checklist name="gu_symptoms" value="dysuria|burning|frequency|urgency|hematuria"][textarea cols=50 rows=2]
[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"][textarea cols=50 rows=2][/conditional]
MSK:
[checklist name="msk_symptoms" value="myalgias|neck pain|back pain|shoulder pain|hip pain|knee pain|joint pain/deformity|localized muscle/soft tissue pain/swelling"][textarea cols=50 rows=2]
Neuro:
[checklist name="neuro_symptoms" value="dizziness|poor balance|tremor|seizures|tingling/numbness"][textarea cols=50 rows=2]
Psych:
[checklist name="psych_symptoms" value="irritability|confusion|withdrawal|depression|anxiety|mood swings|insomnia"][textarea cols=50 rows=2]
Endo:
[checklist name="endo_symptoms" value="hair loss|polyuria"][textarea cols=50 rows=2]
Lymph/Hema:
[checklist name="hem_symptoms" value="gland swelling|bruising|anemia"][textarea cols=50 rows=2]
Immune:
[checklist name="allergy_symptoms" value="atopy|food allergies|autoimmune dz"][textarea cols=50 rows=2]
Derm:
[checklist name="derm_symptoms" value="dryness|pruritus|rash|hives|redness|swelling|wounds"][textarea cols=50 rows=2]



OFFICE DIAGNOSTICS:
[checkbox name="office_diag" value="none performed today||H&H|UA||normal|non-specific changes|no acute findings||discussed with patient/SO|official report to follow|"][textarea cols=50 rows=2]

Appearance:
[checkbox name="appearance" value=" well-appearing young adult|no signs of discomfort visible while sitting in chair|no signs of discomfort visible while ambulating & getting on/off exam table|good hygiene||normal built|heavy built|lean||ill-appearing|tired-looking|short of breath|diaphoretic||disheveled|bizarre clothes|body odor|"][textarea cols=50 rows=2]

Skin:
[checkbox name="skin" value="grossly intact, no rashes|warm and well perfused|no acanthosis nigricans|no hirsutism|no signs of self-injury or abuse||tattoos|body piercings|poor turgor||dry|sweaty|"][textarea cols=50 rows=2]

Head/Face:
[checkbox name="head" value="normocephalic, atraumatic|normal hair distribution|symmetrical face|CN grossly intact||plethoric face|alopecia|facial droop|"][textarea cols=50 rows=2]

Eyes:
[checkbox name="eyes" value="vision 20/30 or better in both eyes, no line difference|failed vision screen||pupils equal round reactive to light|clear conjunctiva w/o exudates or hemorrhage, anicteric sclera, EOM intact without nystagmus|cornea(s) clear||glasses|contacts|conjunctival injection|epiphora|conjunctival exudate|allergic shiners|dysconjugate gaze|"][textarea cols=50 rows=2]

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=50 rows=2]

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=50 rows=2]

Mouth:
[checkbox name="mouth" value="tongue normal in appearance w/o lesions and with good symmetrical movements|moist oral mucosa without lesions|healthy-appearing teeth without visible caries||upper denture|lower denture||poor dentition|oral ulcers|gum swelling|tooth decay|"][textarea cols=50 rows=2]

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=50 rows=2]

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=50 rows=2]

Chest/Lungs:
[checkbox name="lungs" value="unlabored respirations, symmetrical chest expansion|clear and equal breath sounds bilaterally||chest wall atraumatic and non-tender|no axillary or supraclavicular LAD||SOB|decreased bilaterally|wheezing|crackles|"][textarea cols=50 rows=2]

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=50 rows=2]

Abdomen:
[checkbox name="abd" value="normal visual inspection, no distension|normal active bowel sounds|soft non-tender|no obvious palpable masses||protruding|umbilical hernia|diffuse tenderness over entire abdomen w/o RRG|"][textarea cols=50 rows=2]

GU:
[checkbox name="gu" value="declined exam||normal external genitalia|no inguinal LAD|uncircumcised|circumcised||no hydrocele, hernia, varicocele, or masses|no gynecomastia|testicular tenderness|"][textarea cols=50 rows=2]

MSK:
[checkbox name="spine" value="no gross deformities, moves all extremities with good ROM for age|normal curvature & ROM in C- & L-spine for patient’s age||strength, tone, & bulk symmetrical & grossly intact|"][textarea cols=50 rows=2]

Neuro:
[checkbox name="neuro" value="normal concentration and attention|memory grossly intact||balance & coordination grossly intact|ambulates w/o limp or alteration in gait||extremities strong w/o atrophy|no gross motor deficits|sensation symmetrical & grossly intact||no involuntary movements or tremor|"][textarea cols=50 rows=2]

Speech/Vocalization:
[checkbox name="speech" value="normal for age|clear & coherent||slurred|mumbling to self|monotonous|stuttering||hypoverbal|hyperverbal||loud|soft||slow|rapid|pressured||groaning|sighing|crying||perseveration|flight of ideas|repetitive questions||self-depreciating statements|repetitive statements of impending doom|repetitive non-health related/financial concerns||personal safety concerns|suicidal ideation/threats||insisting on particular medication, test, referral, or accommodation||raising voice|defensive|argumentative|cursing, swearing|previous providers/staff criticisms|verbal threats|sexual remarks|racist remarks|"][textarea cols=50 rows=2]

Behavior/Psychomotor Activity:
[checkbox name="behavior" value="calm, pleasant, respectful|cooperative with history & exam||guarded|anxious|irritable|frustrated|labile||agitated|hostile|forceful||pacing|fidgeting|picking skin|twirling hair|cracking knuckles||grimacing, furrowing eyebrows|tightening jaw|breathing hard|intense staring|threatening gestures|fist-clenching||withdrawn|flat affect|bradykinetic|indifferent|appears to be responding to internal psychotic process|"][textarea cols=50 rows=2]

A/P:
[checkbox name="ap" value="well young adult|normal BMI|normal BP|"][textarea cols=50 rows=2]

ORDERS - LABS:
[checkbox name="order_lab" value="none||CBC|CMP|TSH|Lipids|A1C|UA|STI|"][textarea cols=50 rows=2]

ORDERS - RX:
[checkbox name="order_RX" value="none||OTC||electronic|paper|given to MA to be transmitted to pharmacy|"][textarea cols=50 rows=1]

ORDERS - REFERRALS:
[checkbox name="order_refer" value="none|"] [textarea cols=50 rows=2]

ORDERS - FORMS/RELEASE/CLEARANCE:
[checkbox name="clearance" value="none||school physical|"][textarea cols=70 rows=1]

INSTRUCTED ON:
wellness, exam/screening findings, POC, reporting medication side effects immediately, appropriate follow up, indications for immediate direct evaluation and/or contacting emergency services
[textarea cols=50 rows=1]

PLAN OF CARE:
[checkbox name="discussed" value="verbalized understanding of & agreement with POC|did not agree with my POC – will seek second opinion/further care elsewhere|"][textarea cols=50 rows=3]

SAFETY:
[checkbox name="discharge" value="no safety concerns at this time||safety concerns d/t parental knowledge/mood|safety concerns d/t social issues|"][textarea cols=50 rows=2]

FOLLOW UP:
Q3 years sooner if concerns arise|
[checkbox name="next" value="RTC 24 hours|RTC 2-3 days|RTC 1-2 week|RTC 4 weeks|"][textarea cols=50 rows=2]

PARENTAL BEHAVIOR:
[checkbox name="behavior" value="calm|pleasant|respectful||anxious|fearful|suspicious|irritable|frustrated|crying||forceful|insisting on particular medication, test, referral, or accommodation|argumentative||hostile|raising voice|agitated|cursing, swearing||previous providers/staff criticisms|verbal threats|sexual remarks|racist remarks||flat affect|bradykinetic|indifferent|appears to be responding to internal psychotic process|"][textarea cols=50 rows=2]

BARRIERS TO CARE:
[checkbox name="barriers" value="none noted at this time||incomplete history d/t parental anxiety/behavior|incomplete history d/t parental lack of knowledge|incomplete history d/t language barrier||vague shifting complaints|history not supported by objective findings|supporting documentation unavailable||poor cooperation with exam|poor compliance with POC|intolerance of/therapeutic failure on multiple meds||lack of motivation on parent's part|negative parental attitude to diagnostic impression & proposed tx|"][textarea cols=50 rows=1]


CONCERNS/QUESTIONS:


SPECIAL NEEDS:


INTERVAL HISTORY:


MEDICATIONS:


PMH:
reviewed


GROWTH/DEVELOPMENT/ANTICIPATORY GUIDANCE -
discussed and/or handout provided:


VACCINATION:


SCREENING - age-specific questionnaire provided & discussed:


SCHOOL - discussed and/or handout provided:


NUTRITION - discussed and/or handout provided:


DENTAL - discussed and/or handout provided:


INTERPERSONAL - discussed and/or handout provided:


MENTAL HEALTH - discussed and/or handout provided:


PHYSICAL ACTIVITY - discussed and/or handout provided:


SAFETY - discussed and/or handout provided:


TOBACCO, ALCOHOL, DRUGS - discussed and/or handout provided:


SEXUAL - discussed and/or handout provided:




ROS
10-point review of systems was performed and results were negative except for any positive results below

Constitutional:

Head/face:

Eyes:

Ears:

Nose:

Mouth:

Throat:

Neck:

CV:

Chest/Respiratory:

GI:

GU:

GYN
MSK:

Neuro:

Psych:

Endo:

Lymph/Hema:

Immune:

Derm:




OFFICE DIAGNOSTICS:


Appearance:


Skin:


Head/Face:


Eyes:


Ears:


Nose:


Mouth:


Throat:


Neck:


Chest/Lungs:


CV:


Abdomen:


GU:


MSK:


Neuro:


Speech/Vocalization:


Behavior/Psychomotor Activity:


A/P:


ORDERS - LABS:


ORDERS - RX:


ORDERS - REFERRALS:


ORDERS - FORMS/RELEASE/CLEARANCE:


INSTRUCTED ON:
wellness, exam/screening findings, POC, reporting medication side effects immediately, appropriate follow up, indications for immediate direct evaluation and/or contacting emergency services


PLAN OF CARE:


SAFETY:


FOLLOW UP:
Q3 years sooner if concerns arise|


PARENTAL BEHAVIOR:


BARRIERS TO CARE:

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