ROS template

[date name="variable_1" default="01/02/2022"]

Constitutional (positive and negative responses noted below): 
[checklist name="variable_1" value="fevers|weightloss|fatigue|night sweats"]

Head (positive and negative responses noted below): 
[checklist name="variable_2" value="headache|sinus congestion or pain|history of trauma to head"]

Ear (positive and negative responses noted below):
[checklist name="variable_3" value="ear pain|discharge|hearing loss|tinnitus|vertigo"]

Eyes (positive and negative responses noted below):   
[checklist name="variable_4" value="changes in vision|eye pain|diplopia| photophobia| dry eyes| glasses or contacts"]


Nose (positive and negative responses noted below): 


Throat (positive and negative responses noted below): 
cough [select name="variable_1" value="no|yes"]
sore throat [select name="variable_1" value="no|yes"]
dysphagia [select name="variable_1" value="no|yes"]
odynophagia [select name="variable_1" value="no|yes"]

Skin (positive and negative responses noted below): 
diagnosed skin conditions [select name="variable_1" value="no|yes"]
new lesions [select name="variable_1" value="no|yes"]
rashes [select name="variable_1" value="no|yes"]
discoloration [select name="variable_1" value="no|yes"]
dryness [select name="variable_1" value="no|yes"]
hair changes [select name="variable_1" value="no|yes"]

Heme (positive and negative responses noted below): 
easy bruising [select name="variable_1" value="no|yes"]
easy bleeding [select name="variable_1" value="no|yes"]
anemia [select name="variable_1" value="no|yes"]

CV (positive and negative responses noted below): 
chest pain [select name="variable_1" value="no|yes"]
palpitations [select name="variable_1" value="no|yes"]
edema [select name="variable_1" value="no|yes"]
presyncope [select name="variable_1" value="no|yes"]
decrease in exercise tolerance [select name="variable_1" value="no|yes"]

Resp (positive and negative responses noted below): 
expectoration [select name="variable_1" value="no|yes"]
dyspnea with rest or exertion [select name="variable_1" value="no|yes"]
increased puffer use [select name="variable_1" value="no|yes"]
orthopnea [select name="variable_1" value="no|yes"]
PND [select name="variable_1" value="no|yes"]
Wheeze [select name="variable_1" value="no|yes"]

GI (positive and negative responses noted below): 
-	abdominal pain - no
-	nausea - no
-	vomiting- no
-	diarrhea- no
-	constipation- no
-	melena- no
-	appetite changes- no
-	dyspepsia- no
-	belching- no
GU (positive and negative responses noted below): 
-	dysuria- no
-	frequency- no
-	urgency- no
-	hematuria- no
-	nocturia- no
-	incontinence- no
-	dribbling- no
-	hesitancy- no
-	retention- no
-	flank pain- no
Male (positive and negative responses noted below): 
-	discharge - denies 
-	lesions- denies
-	testicular pain- denies
-	hernias- denies
Female (positive and negative responses noted below): 
-	discharge - denies
-	lesions - denies
-	changes in dysmenorrhea - denies
-	 PMS - denies
-	menstrual frequency or duration - denies
-	flow - denies
-	Other symptoms- denies

Musculoskeletal (positive and negative responses noted below): 
-	new weakness- no
-	arthralgias- no
-	myalgias- no

Neuro (positive and negative responses noted below): No 
-	weakness- no
-	confusion- no
-	numbness- no
-	dizziness- no
-	imbalance- no

Endocrine (positive and negative responses noted below): 
-	polydipsia - no
-	polyuria- no
-	heat/cold sensitivity - no

Pain (positive and negative responses noted below): 
-	new or unexplained pain - no

Psychology (positive and negative responses noted below): 
No new or worsening depression, anxiety, or insomnia, stress, anger 

Social (positive and negative responses noted below): No change in home, relationships, employment, substance use, exercise, exposure

Function (positive and negative responses noted below): 
No change in ADLs or IADLS, memory, capacity