WC – 18_21

[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|illness|injury|hospitalization/surgery/procedure||diagnostic/laboratory studies|specialty consults||new/changed medications|ABX use||no changes since last visit|"][textarea cols=50 rows=2]
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||non-contributory|"][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=2]
discussed and/or handout provided: [checkbox name="development" value="normal BMI|high BMI|low BMI||no concerns raised|"][textarea cols=50 rows=2]
SCHOOL - discussed and/or handout provided: [checkbox name="schoool" value="IEP/504/behavior plan||parental/teacher concerns regarding behavioral issues|parental/teacher concerns regarding performance||no concerns raised|"][textarea cols=50 rows=2]
NUTRITION - discussed and/or handout provided: [checkbox name="nutrition" value="adequate daily intake of fruits, vegetables, iron-containing foods, and calcium-containing foods||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||referral submitted||no concerns raised|"][textarea cols=50 rows=2]
PHYSICAL ACTIVITY - discussed and/or handout provided: [checkbox name="physical" value="daily exercise|limiting screen time|behaviors optimizing wellness||no concerns raised|"][textarea cols=50 rows=2]
SAFETY - discussed and/or handout provided: [checkbox name="safety" value="wearing seat belt and helmet|driving and substance use|avoiding 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 identity||safe sex|pregnancy and sexually transmitted infections||not sexually active|sexually active||declined to discuss||no concerns raised|"][textarea cols=50 rows=2]

10-point review of systems was performed and results were negative except for any positive results below
General:[textarea name="variable_5" default=" does not report fever, chills, fatigue, malaise, or weight changes"]
HEENT:[textarea name="variable_6" default=" does not report headaches, vision changes, eye redness/discharge, pain with EOM, facial swelling, earache, ear discharge, nasal congestion, rhinorrhea, snoring, bleeding, mouth sores, changes in taste, sore throat, neck swelling"]
CV:[textarea name="variable_7" default=" does not report chest pain, SOB, palpitations, fainting"]
Pulmonary:[textarea name="variable_8" default=" does not report shortness of breath, cough, wheezing, or chest wall pain with breathing"]
GI:[textarea name="variable_9" default=" does not report poor appetite, nausea, vomiting, abdominal pain, constipation, diarrhea"]
Urinary:[textarea name="variable_10" default=" does not report dysuria, hematuria, frequency"][checkbox memo="GYN" name="gyn" value=" "][conditional field="gyn" condition="(gyn).is(' ')"][textarea name="variable_20" default=" does not report abnormal bleeding|missed period|irregular periods|heavy and/or prolonged periods|passing clots, rash, discharge"][/conditional]
MSK:[textarea name="variable_11" default=" does not report myalgias, arthralgias, muscle/soft tissues pain/swelling, or joint pain/swelling"]
Neurologic:[textarea name="variable_13" default=" does not report dizziness, seizures, tremor, or weakness"]
Psychiatric:[textarea name="variable_14" default=" does not report depression, anxiety, mood swings, or insomnia"]
Dermatologic:[textarea name="variable_12" default=" does not report rashes, redness, pruritus, swelling, or wounds"]
Endocrine:[textarea name="variable_15" default=" does not report night sweats, hair loss, or polyuria"]
Hematologic/lymphatic:[textarea name="variable_16" default=" does not report abnormal bleeding/bruising"]

VACCINATION: [checkbox name="preventative" value="UTD|missing shots||administered today|deferred|declined|"][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]

[checkbox name="ap" value="well young adult|normal BMI|normal BP|"][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 - LABS: [checkbox name="order_lab" value="none||CBC|CMP|TSH|Lipids|A1C|UA|STI|"][textarea cols=50 rows=2]
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: milestones, wellness, screening findings, exam findings, appropriate follow up, [checkbox name="instruct" value="POC, reporting medication side effects immediately, 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: 12 months, 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]





PMH: reviewed

SCREENING - age-specific questionnaire provided & discussed:

discussed and/or handout provided:

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:

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





























Behavior/Psychomotor Activity:






INSTRUCTED ON: milestones, wellness, screening findings, exam findings, appropriate follow up,



FOLLOW UP: 12 months, sooner if concerns arise,



Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.44, 109 form elements, 191 boilerplate words, 60 text areas, 48 checkboxes, 1 conditionals, 545 total clicks
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