Allergy & Otolaryngology
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HPI: [comment memo="URI/URTI Upper Respiratory Tract Infection HPI Template"]
[text size="4"]yo [select value="M|F"] with [comment memo="symptoms"][checkbox name="URTIsx" value="runny nose|stuffy nose|itchy eyes|watery eyes|ear pain|sinus pain in cheeks and/or forehead|sore throat|pain with swallowing|difficulty swallowing|hoarseness|productive cough|dry cough|fever|chills|body aches"] for the past [text size="4"] [select value="day(s)|week(s)"][comment memo="duration"]
[conditional field="URTIsx" condition="(URTIsx).is('ear pain')||(URTIsx).is('sinus pain in cheeks and/or forehead')||(URTIsx).is('sore throat')||(URTIsx).is('pain with swallowing')"]-Pain severity: [text size="4"]/10
[/conditional]-Is sore throat the main complaint without concurrent cold-like symptoms (nose/eyes/etc)? [select name="Centor" value="no|YES"][comment memo="Choose 'yes' to bring up Centor Criteria"][conditional field="Centor" condition="(Centor).is('YES')"]

Modified Centor Score
[select name="Q1Fever" value="No (0 points)=0|YES (1 point)=1"] <-- History of fever or measured temperature > 100.4 degrees F
[select name="Q2Cough" value="Cough is present (0 points)=0|COUGH IS ABSENT (1 point)=1"] <-- Presence of coughing
[select name="Q3Nodes" value="No (0 points)=0|YES (1 point)=1"] <-- Tender anterior cervical nodes
[select name="Q4Tonsil" value="No (0 points)=0|YES (1 point)=1"] <-- Tonsillar swelling or exudates
[select name="Q5Age" value="< 15 years (1 point)=1|15 to 45 years (0 points)=0|> 45 years (-1 point)=-1"] <-- Age
Score --> [calc value="score=(Q1Fever)+(Q2Cough)+(Q3Nodes)+(Q4Tonsil)+(Q5Age)" memo="score"][/conditional]
[comment memo="modifying factors"]
-Therapies tried that have improved symptoms: [text size="50"]
-Therapies tried that have NOT improved symptoms: [text size="50"]
-[comment memo="Additional comments:"][textarea]

Review of Systems:
[radio value="fever"][radio value="chills"][radio value="body aches"][radio value="chest pain"][radio value="nausea"][radio value="vomiting"][radio value="diarrhea"]
[comment memo="For use in CRDAMC FM Clinic"]

Dyspnea
Onset [text] prior to evaluation
Onset while [text]

Now it is of [text] severity at the time of this evaluation.
At it worst it is of [text] severity.

The dyspnea is relieved with [text]
[select value="no|YES"] <-- worse lying flat
[select value="no|YES"] <-- exertional
[select value="no|YES"] <-- worse with coughing

[select value="no|YES"] <-- cough [text] productive of sputum
[select value="no|YES"] <-- wheezing
[select value="no|YES"] <-- chest pain
[select value="no|YES"] <-- palpitations
[select value="no|YES"] <-- fever
[select value="no|YES"] <-- diaphoresis

Pertinent PMH:
[select value="no|YES"] <-- COPD
[select value="no|YES"] <-- Asthma.
[select value="no|YES"] <-- CHF
[select value="no|YES"] <-- Coronary Disease
[select value="no|YES"] <-- Prior Intubations
Tobacco use: [text]

Pertinent Medications:
Albuterol recent use up to every [text] and was last used [text]
Steroid inhaler: [text]
Oral steroids last used: [text]

Pitfalls:
[select value="no|YES"] <-- Pneumothorax history or risk
[select value="no|YES"] <-- Pneumonia history or risk
[select value="no|YES"] <-- unilateral leg swelling
[select value="no|YES"] <-- recent prolonged travel, recent trauma, hypercoagulable state, hormonal therapy
[select value="no|YES"] <-- anxiety related symptoms such as panic, dizziness, or finger paresthesias.
[checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"]
reference:
[link url="//www.fpnotebook.com" memo="#1"] Dr. Scott Moses, creator/author of the Family Practice Notebook
[/conditional]

[comment memo="Use with Cough symptoms Patient Questionnaire"]
[text size="3"]yo [select name="Sex" value="|M|F"] with cough for [text size="4"] [select value="day(s)|hour(s)|week(s)|month(s)"]
[comment memo="Initial questions"]
-Cough is [select name="prod" value="non-productive|productive"][conditional field="prod" condition="(prod).is('productive')"] - sputum color is [text size="20"][/conditional]
-Cough started when/while [text memo="inciting event" size="80"]
-Remedies/medicines attempted: [text size="80"]
-Effect of attempted remedies/medicines: [text size="80"]
-Since onset, sx have [select value="gotten better|gotten worse|stayed about the same"]
-Patient describes severity is [select value="minimal|moderate|severe"]
-Patient feels cough at nighttime [select value="not significantly affecting sleep|preventing adequate sleep"]
-Patient reports [select value="no known|known"] sick contacts at home, school, or work. [text size="40"]
-Other associated symptoms:
--[select value="no|YES"] <-chest pain with coughing
--[select value="no|YES"] <-coughing up blood
--[select value="no|YES"] <-fever/chills
--[select value="no|YES"] <-body aches
--[select value="no|YES"] <-hoarseness
--[select value="no|YES"] <-sore throat
--[select value="no|YES"] <-runny/stuffy nose
--[select value="no|YES"] <-ear pain
--[select value="no|YES"] <-sinus pain
--[select value="no|YES"] <-itchy/watery eyes
--[select value="no|YES"] <-pain with swallowing
--[select value="no|YES"] <-feeling of lump in throat (globus sensation)
-Hx of these conditions:
--[select value="no|YES"] <-recent cold
--[select value="no|YES"] <-allergic rhinitis
--[select value="no|YES"] <-non-allergic rhinitis
--[select value="no|YES"] <-frequent sinus infection
--[select value="no|YES"] <-asthma
--[select value="no|YES"] <-frequent pneumonia
--[select value="no|YES"] <-frequent bronchitis
--[select value="no|YES"] <-GERD
--[select value="no|YES"] <-head/neck/throat/thyroid/lung cancer
--[select value="no|YES"] <-tuberculosis or positive tuberculin skin test
--[select value="no|YES"] <-Diabetes Mellitus

Tobacco: [checkbox name="tobacco" value="never smoked/chewed/dipped/vaped tobacco/nicotine products|currently smokes/chews/dips/vapes tobacco/nicotine products|formerly smoked/chewed/dipped/vaped tobacco/nicotine products|regularly exposed to second-hand smoke"][conditional field="tobacco" condition="(tobacco).is('currently smokes/chews/dips/vapes tobacco/nicotine products')||(tobacco).is('formerly smoked/chewed/dipped/vaped tobacco/nicotine products')"] [text memo="#packs per day & #years & how long ago quit if applicable" size="20"][/conditional].

Travel: recent travel in past 6 months to foreign country and regular close contact with local people where tuberculosis is endemic- [select value="no|YES"] [text size="50"]

Immunizations: [select value="vaccines UTD per CDC schedule including pertussis|PERTUSSIS VACCINATION STATUS UNKNOWN|UNVACCINATED TO PERTUSSIS"]

[conditional field="Sex" condition="(Sex).is('F')"]
-Currently pregnant- [select name="pg" value="|no|unsure|YES"][/conditional][conditional field="pg" condition="(pg).is('no')||(pg).is('unsure')"]
-Current contraception method: [text size="40"]
-LMP: [text size="10"][/conditional]
[textarea memo="add'l comments"]
[comment memo="For use in CRDAMC FM Clinic"]

[select value="less than 1 day|1 day|2 days|3 days|4 days|5 days|6 days|7 days|more than 1 week|more than 1 month"] <-- duration
[select value="no|YES"] <-- nasal congestion
[select value="no|YES"] <-- nasal discharge
[select value="no|YES"] <-- sneezing
[select value="no|YES"] <-- watery eyes
[select value="no|YES"] <-- cough
[select value="no|YES"] <-- headache
[select value="no|YES"] <-- fever
[select value="no|YES"] <-- past history of similar symptoms
Allergies identified
[select value="no|YES"] <-- ragweed
[select value="no|YES"] <-- tree pollen
[select value="no|YES"] <-- mold
[select value="no|YES"] <-- grass
[select value="no|YES"] <-- animal dander
Prior treatment
[select value="no|YES"] <-- over the counter antihistamines
[select value="no|YES"] <-- loratidine
[select value="no|YES"] <-- fexofenadine
[select value="no|YES"] <-- cetirizine
[select value="no|YES"] <-- intranasal steroids
Past History
[select value="no|YES"] <-- asthma
[select value="no|YES"] <-- eczema
[textarea]
[textarea name="variable_1" default="sample text"]
[textarea name="variable_1" default="sample text"]
[textarea name="variable_1" default="sample text"]
[textarea name="variable_1" default="sample text"]

-Symptoms-[checkbox value="watery runny nose|frequent sneezing|nasal blockage/stuffiness|itchy nose|Watery/red/itchy eyes|itchy throat|lump in throat (globus sensation)"]
-Worst/most-bothersome symptom- [select value="watery runny nose|frequent sneezing|nasal blockage/stuffiness|itchy nose|Watery/red/itchy eyes|itchy throat|lump in throat (globus sensation)"]
-Onset- [text size="3"] [select value="months|years"] ago
-Frequency of symptoms- [text size="20"]
-How bothersome symptoms are to patient? - [text size="3"]/7
[comment memo="Severity scale explanation:
1= None- occasional limited episode
3= Mildly bothersome- steady symptoms but easily tolerable
5= Moderately bothersome- symptoms hard to tolerate, may interfere with daily activities and/or sleep
7= Unbearably severe- symptoms are so bad, person can't function all the time" memo_size="small"]
-Symptom Triggers-
[select value="no|YES"]<-Pollen from trees, flowers and grasses
[select value="no|YES"]<-Mold (both indoors and outdoors)
[select value="no|YES"]<-Furred animals (especially cats, dogs and mice)
[select value="no|YES"]<-Dust mites
[select value="no|YES"]<-Specific seasons
[select value="no|YES"]<-Weather/temperature changes (esp. cold temperatures)
[select value="no|YES"]<-Tobacco smoke
[select value="no|YES"]<-Strong fumes (ie. vehicle exhaust or chemicals)
[select value="no|YES"]<-Perfumes
[select value="no|YES"]<-Spicy foods (more than just mild runny nose)
[select value="no|YES"]<-Other allergens: [text size="50"]
-Current treatment(s)-
[checkbox value="none"][checkbox memo="(ie. claritin/allegra/zyrtec)" memo_size="small" value="oral antihistamine"][checkbox memo="(ie. flonase/nasonex)" memo_size="small" value="intranasal steroids"][checkbox memo="(ie. astelin/patanase)" memo_size="small" value="intranasal antihistamine"][checkbox memo="(ie. sudaphed or phenyleprhine)" memo_size="small" value="oral decongestant"][checkbox memo="(ie. afrin/neosynephrine" memo_size="small" value="intranasal decongestant"][checkbox value="intranasal capsaicin"][checkbox value="nasal rinse kit"]. [text memo="other treatments if any" size="50"]
-Prior treatment(s)
[checkbox value="none"][checkbox memo="(ie. claritin/allegra/zyrtec)" memo_size="small" value="oral antihistamine"][checkbox memo="(ie. flonase/nasonex)" memo_size="small" value="intranasal steroids"][checkbox memo="(ie. astelin/patanase)" memo_size="small" value="intranasal antihistamine"][checkbox memo="(ie. sudaphed or phenyleprhine)" memo_size="small" value="oral decongestant"][checkbox memo="(ie. afrin/neosynephrine" memo_size="small" value="intranasal decongestant"][checkbox value="intranasal capsaicin"][checkbox value="nasal rinse kit"][checkbox value="surgery"]. [text memo="other treatments if any" size="50"]
-Effect of these: [textarea]
-Past Medical History of:
[select value="no|YES"] <-- asthma
[select value="no|YES"] <-- eczema
-Further/other details:
[textarea]
[comment memo="7-point severity scale adapted from Wallace DV, Dykewicz MS, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, Lang DM, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph CC, Schuller D, Spector SL, Tilles SA. The diagnosis and management of rhinitis: An updated practice parameter. Journal of Allergy and Clinical Immunology. 2008;122(2):S1-S84." memo_size="small"]
[comment memo="For use in CRDAMC FM Clinic"]
HPI: URI/URTI Upper Respiratory Tract Infection HPI Template
yo with symptoms for the past duration
-Is sore throat the main complaint without concurrent cold-like symptoms (nose/eyes/etc)? Choose 'yes' to bring up Centor Criteria
modifying factors
-Therapies tried that have improved symptoms:
-Therapies tried that have NOT improved symptoms:
-Additional comments:

Review of Systems:

For use in CRDAMC FM Clinic

Dyspnea
Onset prior to evaluation
Onset while

Now it is of severity at the time of this evaluation.
At it worst it is of severity.

The dyspnea is relieved with
<-- worse lying flat
<-- exertional
<-- worse with coughing

<-- cough productive of sputum
<-- wheezing
<-- chest pain
<-- palpitations
<-- fever
<-- diaphoresis

Pertinent PMH:
<-- COPD
<-- Asthma.
<-- CHF
<-- Coronary Disease
<-- Prior Intubations
Tobacco use:

Pertinent Medications:
Albuterol recent use up to every and was last used
Steroid inhaler:
Oral steroids last used:

Pitfalls:
<-- Pneumothorax history or risk
<-- Pneumonia history or risk
<-- unilateral leg swelling
<-- recent prolonged travel, recent trauma, hypercoagulable state, hormonal therapy
<-- anxiety related symptoms such as panic, dizziness, or finger paresthesias.
display/hide references

Use with Cough symptoms Patient Questionnaire
yo with cough for
Initial questions
-Cough is
-Cough started when/while inciting event
-Remedies/medicines attempted:
-Effect of attempted remedies/medicines:
-Since onset, sx have
-Patient describes severity is
-Patient feels cough at nighttime
-Patient reports sick contacts at home, school, or work.
-Other associated symptoms:
-- <-chest pain with coughing
-- <-coughing up blood
-- <-fever/chills
-- <-body aches
-- <-hoarseness
-- <-sore throat
-- <-runny/stuffy nose
-- <-ear pain
-- <-sinus pain
-- <-itchy/watery eyes
-- <-pain with swallowing
-- <-feeling of lump in throat (globus sensation)
-Hx of these conditions:
-- <-recent cold
-- <-allergic rhinitis
-- <-non-allergic rhinitis
-- <-frequent sinus infection
-- <-asthma
-- <-frequent pneumonia
-- <-frequent bronchitis
-- <-GERD
-- <-head/neck/throat/thyroid/lung cancer
-- <-tuberculosis or positive tuberculin skin test
-- <-Diabetes Mellitus

Tobacco: .

Travel: recent travel in past 6 months to foreign country and regular close contact with local people where tuberculosis is endemic-

Immunizations:


add'l comments
For use in CRDAMC FM Clinic

<-- duration
<-- nasal congestion
<-- nasal discharge
<-- sneezing
<-- watery eyes
<-- cough
<-- headache
<-- fever
<-- past history of similar symptoms
Allergies identified
<-- ragweed
<-- tree pollen
<-- mold
<-- grass
<-- animal dander
Prior treatment
<-- over the counter antihistamines
<-- loratidine
<-- fexofenadine
<-- cetirizine
<-- intranasal steroids
Past History
<-- asthma
<-- eczema






-Symptoms-
-Worst/most-bothersome symptom-
-Onset- ago
-Frequency of symptoms-
-How bothersome symptoms are to patient? - /7
Severity scale explanation:
1= None- occasional limited episode
3= Mildly bothersome- steady symptoms but easily tolerable
5= Moderately bothersome- symptoms hard to tolerate, may interfere with daily activities and/or sleep
7= Unbearably severe- symptoms are so bad, person can't function all the time

-Symptom Triggers-
<-Pollen from trees, flowers and grasses
<-Mold (both indoors and outdoors)
<-Furred animals (especially cats, dogs and mice)
<-Dust mites
<-Specific seasons
<-Weather/temperature changes (esp. cold temperatures)
<-Tobacco smoke
<-Strong fumes (ie. vehicle exhaust or chemicals)
<-Perfumes
<-Spicy foods (more than just mild runny nose)
<-Other allergens:
-Current treatment(s)-
(ie. claritin/allegra/zyrtec) (ie. flonase/nasonex) (ie. astelin/patanase) (ie. sudaphed or phenyleprhine) (ie. afrin/neosynephrine . other treatments if any
-Prior treatment(s)
(ie. claritin/allegra/zyrtec) (ie. flonase/nasonex) (ie. astelin/patanase) (ie. sudaphed or phenyleprhine) (ie. afrin/neosynephrine . other treatments if any
-Effect of these:
-Past Medical History of:
<-- asthma
<-- eczema
-Further/other details:

7-point severity scale adapted from Wallace DV, Dykewicz MS, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, Lang DM, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph CC, Schuller D, Spector SL, Tilles SA. The diagnosis and management of rhinitis: An updated practice parameter. Journal of Allergy and Clinical Immunology. 2008;122(2):S1-S84.
For use in CRDAMC FM Clinic

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