Rhinitous/Dyspnea/Cough
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"]
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Sandbox Metrics: Structured Data Index 0.74, 110 form elements, 405 boilerplate words, 22 text boxes, 4 text areas, 2 checkboxes, 73 drop downs, 1 links, 3 comments, 5 conditionals, 104 total clicks
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