Generic Visit Note – JD 2

Date and Time of Service:[date default="today"] [text default="Time:"]

Chief Complaints: 
[textarea cols=80 rows=1 default="one or more symptoms in patient's words, duration..."]

History of Present Illness: 
[textarea cols=80 rows=5 default="OPPQRSTA - Onset (When did it begin?), Provocation (What makes it worse), Palliation (What makes it better?), Quality (What type of pain/ what does it feel like?), Radiation/Location (Where is the pain and does the pain travel anywhere?), Severity (How bad is it on a scale of 0-10?), Time (How long does it last? How frequently does it happen? When does it happen?), Associated Symptoms (Anything else that happens with it?)"]

Past Medical History: 
[textarea cols=80 rows=4 default="chronic illness, important prior illness, injuries, and for how long, etc.)"]

Medications: 
[textarea cols=80 rows=5 default="medication name/dose/indication/duration. OTC, Rx, supplements, vitamins AND Dose and Frequency!"]

Allergies and Medication Intolerances: 
[textarea cols=80 rows=1 default="medication or substance and reaction."]

Past Surgical History: 
[textarea cols=80 rows=4 default="Important prior operations. What, When and any complications?"]

Past Hospitalizations and ER Visits: 
[textarea cols=80 rows=4 default="Prior hospitalizations, What/why, When and any complications?"]

Preventive Care Services/Care Gaps/Vaccinations: 
[textarea cols=80 rows=1 default="dates and results of screening tests, exams, vaccinations and/or gaps in care/screening"]

Social History: [textarea cols=80 rows=3 default=" Place of birth, nationality and ethnicity, marital status, occupations, military history, gender preference, social and economic status, habits, violence and safety, prostheses and in-home assistance"]
-Diet: [textarea cols=80 rows=3 default=" Diet"]
-Exercise: [textarea cols=80 rows=3 default=" Exercise"]
-Drug Usage: [textarea cols=80 rows=3 default=" Any drug usage EVER. Consider, 1st dose, last dose, + frequency"]
-Tobacco Usage: [textarea cols=80 rows=3 default=" Do you or have you ever used tobacco to include chew, smoke, or vaping and for how long. Use information to calculate pack years i.e. # of Packs a day / year’s"]
-Alcohol Usage: [textarea cols=80 rows=3 default=" How much, how frequently, what size how long?"]
-Caffeine Usage: [textarea cols=80 rows=3 default=" How much, how frequently, what size how long?"]
-Occupation: [textarea cols=80 rows=3 default=" What do they do for a living"]
-Sex History: [textarea cols=80 rows=3 default=" Partner, Practice, Protection, Previous STI, Pregnancy, Birth Control"]

Family History: 
[textarea cols=80 rows=3 default="history for first-degree relatives or beyond. Living? Current age or age of death? Medical conditions?"]

Advance Directives: 
[textarea cols=80 rows=1 default="living will and/or durable power of attorney for health care/identify surrogate decision maker"]

[checkbox name="MasterROS" memo="ROS" memo_size="large" value=""][conditional field="MasterROS" condition="(MasterROS).is('')"]
Review of Systems:
[textarea cols=80 rows=1 default="General: (-) fever, night sweats, unexplained weight loss"]
[textarea cols=80 rows=1 default="SKIN: (-) rashes, bruising, nail or hair changes"]
[textarea cols=80 rows=1 default="HEME/LYMPH: (-) bleeding, bruising, swollen lymph nodes"]
[textarea cols=80 rows=1 default="HEENT: (-) no headache, vision changes, hearing loss, vertigo, nose bleeds, sinusitis, dysphagia, pain/trouble swallowing, hoarseness"]
[textarea cols=80 rows=1 default="NECK: (-) painful nodes."]
[textarea cols=80 rows=1 default="ENDOCRINE: (-) tremor, palpitations, heat or cold intolerance, unusual fatigue; (-) polyuria/polydipsia/polyphagia"]
[textarea cols=80 rows=1 default="RESPIRATORY: (-) cough, sputum, SOB, chest pain."]
[textarea cols=80 rows=1 default="CARDIOVASCULAR: (-) CP, heaviness, jaw or arm pain, palpitations, leg pain with exercise, edema."]
[textarea cols=80 rows=1 default="GASTROINTESTINAL: (-) constipation, diarrhea, blood in stool, melena, or abdominal pain, nausea, vomiting, abnormal stools."]
[textarea cols=80 rows=1 default="GENITOURINARY: (-) dysuria, frequency, blood in urine, incontinence, nocturia"]
[textarea cols=80 rows=1 default="MUSCULOSKELETAL: (-) pain/swelling in muscles, joints or stiffness, cramps, and weakness."]
[textarea cols=80 rows=1 default="NEUROLOGICAL: (-) weakness, headache, seizure, weakness, syncope, numbness, radiating pain or other pain."]
[textarea cols=80 rows=1 default="PSYCHIATRIC: (-) depression, increased or decreased sleep, mood changes, anxiousness, panic attacks, decreased energy, forgetfulness, hallucinations, suicidal or homicidal ideation."]

[/conditional] 

Physical Exam:

[checkbox name="Problem410" value="GCS Score:"] [conditional field="Problem410" condition="(Problem410).is('GCS Score:')"] Glasgow Coma Scale (GCS)

Best Eye Opening Response: [select name="eye" value="Spontaneous (4 points)=4|Opens to verbal command (3 point)=3|Eyes open to pain (2 points)=2|No eye opening (0 points)=0"]
Verbal Response: [select name="verbal" value="Oriented (5 points)=5|Confused but answering questions (4 point)=4|Inappropriate response, words discernible (3 points)=3|Incomprehensible sounds or speech (2 points)=2|No verbal response (1 point)=1"]
Motor Response: [select name="motor" value="Obeys commands (6 points)=6|Purposeful movement to painful stimuli (5 points)=5|Withdraws from pain (4 points)=4|Abnormal flexion (decorticate) (3 points)=3|Abnormal extension (decerberate)(2 points)=2|No motor response (1 point)=1"]

Total score: [calc value="(eye)+(verbal)+(motor)" memo="score"] (maximum=15)
[/conditional] 

[checkbox name="examchaperone" memo="Chaperone" value=""][conditional field="examchaperone" condition="(examchaperone).is('')"]-Chaperone - [text size="60"][/conditional] 

[checkbox name="examothers" memo="Additional Individuals Present During History and Physical" value=""][conditional field="examothers" condition="(examothers).is('')"]-Additional Individuals Present During History and Physical - [text size="60"]

[/conditional]

[checkbox name="vitals" memo="Vitals" value=""][conditional field="vitals" condition="(vitals).is('')"]-Vitals - [select name="vitals1" value="reviewed, no remarkable abnormalities|significant for|"] [text size="50"] [textarea default="HR: RR: BP: T: SPO2: Ht: W: BMI: "]

[/conditional]

[checkbox name="briefexam" memo="Brief Visual Exam" value=""][conditional field="briefexam" condition="(briefexam).is('')"]
-GENERAL APPEARANCE: [textarea default=" Well developed, well nourished, alert and cooperative, and appears to be in no acute distress." size="80"]

-EYES: [textarea default=" PERRL, EOMI. Fundi normal, vision is grossly intact. Visual acuity 20/20 bilaterally, with correction. Sclera white, conjunctiva pink. Pupils equally round and reactive to light and accommodation, measuring 4 mm and constricting to 2mm. Disc margins are sharp, no hemorrhages, exudates, or AV narrowing noted." size="80"]

-HENT: [textarea default=" Head - Normocephalic / atraumatic. Hair with average texture. Ears - Good acuity to cotton rub. TMs with good cone of light. AC > BC. Nose - Mucosa pink, midline septum, no sinus tenderness. Throat - Oral mucosa moist and pink, good dentition, no exudates noted on pharynx. Teeth and gingiva in good general condition." size="80"]

-NECK: [textarea default=" No JVD. Neck supple, non-tender without lymphadenopathy, masses or thyromegaly." size="80"]

-CARDIAC: [textarea default=" Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits. All pulses are 2+ and symmetric. No femoral or abdominal bruits. " size="80"]

-LUNGS: [textarea default=" Clear to auscultation and percussion bilaterally without rales, rhonchi, wheezing or diminished breath sounds." size="80"]

-ABDOMEN: [textarea default=" Positive bowel sounds. Soft, nondistended, nontender. No guarding or rebound. No masses." size="80"]

-MUSKULOSKELETAL: [textarea default=" No joint erythema or tenderness. Normal muscular development. Normal gait. " size="80"]

-UPPER EXTREMITIES: [textarea default=" No significant deformity or joint abnormality. No edema. Peripheral pulses intact. No varicosities. No asymmetry, redness, swelling, bruising, deformities, lesions, or masses. No tenderness to palpation of the muscles and joints. No tissue texture abnormalities. Full range of motion in all joints. Strength 5/5 throughout." size="80"]

-LOWER EXTREMITIES: [textarea default=" No significant deformity or joint abnormality. No edema. Peripheral pulses intact. No varicosities. No tenderness to palpation of the muscles and joints. No tissue texture abnormalities. Examination of both ankles, knees, legs, and hips reveals normal range of motion, normal sensation without tenderness, swelling, discoloration, crepitus, weakness or deformity and strength 5/5 throughout. Examination of both feet reveals all toes to be normal in size and symmetry, normal range of motion, normal sensation with distal capillary filling of less than 2 seconds without tenderness, swelling, discoloration, nodules, weakness or deformity" size="80"]

-NEUROLOGICAL: [textarea default=" No focal deficits noted. Mental Status - Alert, oriented x3, and cooperative. Coherent thought processes. Cranial Nerves - I not tested, II-XII intact. Motor - Good muscle tone and bulk. Strength 5/5 in all major muscle groups. Cerebellar - Rapid alternating movements, finger-to-nose intact. Gait with normal base. Maintains balance during Romberg. No pronator drift. Sensory - Pinprick, light touch, position, and vibration intact. Reflexes - 2+ throughout, down going plantar reflexes." size="80"]

-SKIN: [textarea default=" Skin normal color, texture and turgor with no lesions or eruptions." size="80"]

-PSYCHIATRIC: [textarea default=" Normal mood and affect. The mental examination revealed the patient was oriented to person, place, and time. The patient was able to demonstrate good judgement and reason, without hallucinations, abnormal affect or abnormal behaviors during the examination. Patient is not suicidal." size="80"]

-[textarea default=" Genitalia, Rectum, Breast, Prostate, etc. Breasts:e.g.1. Symmetric and smooth without nodules or masses palpated. No nipple discharge. No axillary lymphadenopathy. Male Genitalia: e.g.1. No penile lesions or discharge, circumcised. No scrotal swelling or discoloration. Smooth testes descended bilaterally, no masses felt. Nontender epididymis. No inguinal or femoral hernias. No inguinal adenopathy. Female Genitalia: e.g.1. External genitalia with no erythema, lesions, or masses. Pink vaginal mucosa. Parous, pink cervix with no discharge. Uterus anterior, midline, smooth, not enlarged. No adnexal tenderness. Rectovaginal wall intact. No masses felt in rectal vault. No inguinal adenopathy. Pap smear obtained. Stool brown and negative for fecal blood. Anus/Rectum/Prostate: e.g.1. No perirectal lesions, warts, discharge, fissures. Intact external sphincter tone. Rectal vault without masses. Brown stool, no fecal blood. Male: Prostate smooth, nontender with palpable median sulcus. Female: Nontender uterine cervix.
" size="80"]

[/conditional][checkbox name="gendetailexam" memo="*" memo_size="small" value="-General - "][conditional field="gendetailexam" condition="(gendetailexam).is('-General - ')"][checkbox name="examgen" value="well developed|well nourished|A&Ox4|NAD"];[comment memo="abnormals" memo_size="small" memo_color="orange" value=""][checkbox value="MILDLY ILL|SLEEPY|APPEARS CONFUSED|APPEARS LETHARGIC|CACHECTIC APPEARANCE|APPEARS OLDER THAN STATED AGE"] [textarea memo="General free text" memo_size="small" rows="2"]

[/conditional][checkbox name="heentdetailexam" memo="*" memo_size="small" value="-HEENT - "][conditional field="heentdetailexam" condition="(heentdetailexam).is('-HEENT - ')"][checkbox name="examheent" value="normocephalic|atraumatic|conjunctiva clear|sclerae anicteric|TMs with clearly visible landmarks|nares patent b/l|turbinates nonedematous/nonerythematous b/l|mucous membranes moist|throat nonerythematous/noninjected|good dentition"];[comment memo="abnormals" memo_color="orange" memo_size="small"][checkbox value="R CONJUNCTIVAL ERYTHEMA|L CONJUNCTIVAL ERYTHEMA|R TM OPAQUENESS & LOSS OF LANDMARKS|R TM VIEW OBSCURRED BY CERUMEN|L TM OPAQUENESS & LOSS OF LANDMARKS|L TM VIEW OBSCURRED BY CERUMEN|NASAL SEPTUM DEVIATION|R TURBINATE EDEMA|R TURBINATE ERYTHEMA|L TURBINATE EDEMA|L TURBINATE ERYTHEMA|NASAL DISCHARGE|PHARYNGEAL ERYTHEMA/INJECTION|PHARYNGEAL COBBLESTONING|TONSILS INJECTED/EDEMATOUS|TONSILS WITH EXUDATE|GLOSSAL HYPERTROPHY|UVULAR DEVIATION"] [textarea memo="HEENT free text" memo_size="small" rows="2"]

[/conditional][checkbox name="neckdetailexam" memo="*" memo_size="small" value="-Neck - "][conditional field="neckdetailexam" condition="(neckdetailexam).is('-Neck - ')"][checkbox name="examneck" value="soft/supple|no JVD|no thyromegaly|no tender/enlarged lymph nodes"]; [comment memo="abnormals" memo_color="orange" memo_size="small"][checkbox value="R ANTERIOR CHAIN LYMPHADENOPATHY|R POSTERIOR CHAIN LYMPHADENOPATHY|L ANTERIOR CHAIN LYMPHADENOPATHY|L POSTERIOR CHAIN LYMPHADENOPATHY|JUGULAR VENOUS DISTENSION|GOITER"] [textarea memo="Neck free text" memo_size="small" rows="2"]

[/conditional][checkbox name="chestdetailexam" memo="*" memo_size="small" value="-Chest - "][conditional field="chestdetailexam" condition="(chestdetailexam).is('-Chest - ')"][checkbox name="examchest" value="normal rise and fall B/L|no accessory muscle use"]; [comment memo="abnormals" memo_color="orange" memo_size="small"][checkbox value="INTERCOSTAL RETRACTIONS|SUPRACOSTAL RETRACTIONS|INFRACOSTAL RETRACTIONS|PECTUS EXCAVATUM|PECTUS CARINATUM"]  [textarea memo="Chest free text" memo_size="small" rows="2"]

[/conditional][checkbox name="heartdetailexam" memo="*" memo_size="small" value="-Heart - "][conditional field="heartdetailexam" condition="(heartdetailexam).is('-Heart - ')"][checkbox value="RRR|normal S1/S2|No M/R/G|No S3/S4 auscultated|no friction rub"]; [comment memo="abnormals" memo_color="orange" memo_size="small"][checkbox name="examheartabn1" value="MURMUR AUSCULTATED"][/conditional][conditional field="examheartabn1" condition="(examheartabn1).is('MURMUR AUSCULTATED')"] - GRADE [text size="3"]/6 [select value="SYSTOLIC EJECTION|SYSTOLIC|DIASTOLIC|HOLOSYSTOLIC"] HEARD BEST AT [select value="R|L"] [select value="UPPER STERNAL BORDER|LOWER STERNAL BORDER|APEX"]
[/conditional][conditional field="heartdetailexam" condition="(heartdetailexam).is('-Heart - ')"] [textarea memo="Heart free text" memo_size="small" rows="2"]

[/conditional][checkbox name="lungsdetailexam" memo="*" memo_size="small" value="-Lungs - "][conditional field="lungsdetailexam" condition="(lungsdetailexam).is('-Lungs - ')"][checkbox value="CTAB|BSE b/l|no wheezes|no crackles|no rhonchi"]; [comment memo="abnormals" memo_color="orange" memo_size="small"][checkbox name="examlungsabn1" value="WHEEZING-"][/conditional][conditional field="examlungsabn1" condition="(examlungsabn1).is('WHEEZING-')"] [checkbox value="EXPIRATORY|INSPIRATORY|B/L LUNGS|R LUNG|L LUNG|DIFFUSE|LOWER FIELD(S)|UPPER FIELD(S)"];[/conditional][conditional field="lungsdetailexam" condition="(lungsdetailexam).is('-Lungs - ')"][checkbox name="examlungsabn2" value="RHONCHI-"][/conditional][conditional field="examlungsabn2" condition="(examlungsabn2).is('RHONCHI-')"] [checkbox value="EXPIRATORY|INSPIRATORY|B/L LUNGS|R LUNG|L LUNG|DIFFUSE|LOWER FIELD(S)|UPPER FIELD(S)"];[/conditional][conditional field="lungsdetailexam" condition="(lungsdetailexam).is('-Lungs - ')"][checkbox name="examlungsabn3" value="BREATH SOUNDS DIMINISHED-"][/conditional][conditional field="examlungsabn3" condition="(examlungsabn3).is('BREATH SOUNDS DIMINISHED-')"] [checkbox value="B/L LUNGS|R LUNG|L LUNG|DIFFUSE|LOWER FIELD(S)|UPPER FIELD(S)"];[/conditional][conditional field="lungsdetailexam" condition="(lungsdetailexam).is('-Lungs - ')"] [textarea memo="free text" memo_size="small" rows="2"]

[/conditional][checkbox name="ABDdetailexam" memo="*" memo_size="small" value="-Abdomen - "][conditional field="ABDdetailexam" condition="(ABDdetailexam).is('-Abdomen - ')"][checkbox value="soft|nontender|nondistended|no voluntary/involuntary guarding|no rigidity|no rebound|bowel sounds present in all 4 quadrants"]; [comment memo="abnormals" memo_color="orange" memo_size="small"]
[checkbox name="examABDabn1" value="TTP-"][/conditional][conditional field="examABDabn1" condition="(examABDabn1).is('TTP-')"] [checkbox value="MILD|MODERATE|EXQUISITE|OUT OF PROPORTION TO EXAM|RUQ|EPIGASTRIC AREA|LUQ|RLQ|LLQ|PERIUMBILICAL|SUPRAPUBIC"];[/conditional][conditional field="ABDdetailexam" condition="(ABDdetailexam).is('-Abdomen - ')"][checkbox name="examABDabn2" value="BOWEL SOUNDS-"][/conditional][conditional field="examABDabn2" condition="(examABDabn2).is('BOWEL SOUNDS-')"] [checkbox value="HYPOACTIVE|HYPERACTIVE|RUQ|LUQ|RLQ|LLQ|DIFFUSELY"];[/conditional][conditional field="ABDdetailexam" condition="(ABDdetailexam).is('-Abdomen - ')"][checkbox name="examABDabn3" value="PALPABLE MASS-"][/conditional][conditional field="examABDabn3" condition="(examABDabn3).is('PALPABLE MASS-')"] APPROXIMATE SIZE - [text size="5"] CM, [checkbox value="RUQ|LUQ|RLQ|LLQ|MIDLINE|PERIUMBILICAL|PULSATILE"];[/conditional][conditional field="ABDdetailexam" condition="(ABDdetailexam).is('-Abdomen - ')"][checkbox value="VISIBLE SCAR(S)"] [textarea memo="Abdomen free text" memo_size="small" rows="2"]

[/conditional][checkbox name="GUdetailexam" memo="*" memo_size="small" value="-GU - "][conditional field="GUdetailexam" condition="(GUdetailexam).is('-GU - ')"][checkbox name="GUdetailexamfemale" memo="female" memo_size="small" memo_color="red" value=""][/conditional][conditional field="GUdetailexamfemale" condition="(GUdetailexamfemale).is('')"][checkbox name="examGUF" value="normal appearance of external genitalia|normal appearance of vagina|normal appearance of vaginal mucosa|no vaginal discharge|no cervical discharge|no CMT|no uterine tenderness|no adnexal tenderness|IUD string visualized|no tender inguinal lymphadenopathy b/l"]; [comment memo="abnormals" memo_color="orange" memo_size="small"][checkbox name="examGUabnF1" value="VAGINAL DISCHARGE-"][/conditional][conditional field="examGUabnF1" condition="(examGUabnF1).is('VAGINAL DISCHARGE-')"] [text default="color/consistency-" size="80"];[/conditional][conditional field="GUdetailexamfemale" condition="(GUdetailexamfemale).is('')"][checkbox name="examGUabnF2" value="VAGINAL MUCOSA-"][/conditional][conditional field="examGUabnF2" condition="(examGUabnF2).is('VAGINAL MUCOSA-')"] [text size="80"];[/conditional][conditional field="GUdetailexamfemale" condition="(GUdetailexamfemale).is('')"][checkbox name="examGUabnF3" value="VAGINAL TENDERNESS|CERVICAL MOTION TENDERNESS|CERVICAL DISCHARGE-"][/conditional][conditional field="examGUabnF3" condition="(examGUabnF3).is('CERVICAL DISCHARGE-')"] [text default="color/consistency-" size="80"];[/conditional][conditional field="GUdetailexamfemale" condition="(GUdetailexamfemale).is('')"][checkbox name="examGUabnF4" value="ADNEXAL TENDERNESS|ADNEXAL MASS-"][/conditional][conditional field="examGUabnF4" condition="(examGUabnF4).is('ADNEXAL MASS-')"] [text default="location-" size="80"];[/conditional][conditional field="GUdetailexam" condition="(GUdetailexam).is('-GU - ')"][checkbox name="GUdetailexamMale" memo="male" memo_size="small" memo_color="blue" value=""][/conditional][conditional field="GUdetailexamMale" condition="(GUdetailexamMale).is('')"][checkbox value="penis normal appearance|penis normal palpatory texture|no penile discharge|scrotum normal appearance b/l|no scrotal ecchymosis/edema/erythema|scrotum freely mobile b/l|testes descended b/l|no palpatory testicular mass b/l|cremasteric reflex intact b/l|no palpable epididymal mass b/l|no palpable inguinal hernia on exam b/l|no tender inguinal lymphadenopathy b/l"][comment memo="for skin masses use 'Skin' section" memo_size="small"]; [comment memo="abnormals" memo_color="orange" memo_size="small"][checkbox name="examGUabnM1" value="PENILE DISCHARGE-"][/conditional][conditional field="examGUabnM1" condition="(examGUabnM1).is('PENILE DISCHARGE-')"] [text default="color/consistency-" size="80"];[/conditional][conditional field="GUdetailexamMale" condition="(GUdetailexamMale).is('')"][checkbox name="examGUabnM2" value="URETHRAL MEATUS-"][/conditional][conditional field="examGUabnM2" condition="(examGUabnM2).is('URETHRAL MEATUS-')"] [text size="80"];[conditional field="GUdetailexamMale" condition="(GUdetailexamMale).is('')"][checkbox name="examGUabnM3" value="PENIS TENDERNESS TO PALPATION|SCROTAL TENDERNESS TO PALPATION-"][/conditional][conditional field="examGUabnM3" condition="(examGUabnM3).is('SCROTAL TENDERNESS TO PALPATION-')"] [text default="location/severity-" size="80"];[/conditional][conditional field="GUdetailexamMale" condition="(GUdetailexamMale).is('')"][checkbox name="examGUabnM4" value="PALPABLE SCROTAL MASS-"][/conditional][conditional field="examGUabnM4" condition="(examGUabnM4).is('PALPABLE SCROTAL MASS-')"] palpable mass located [select value="R|L|B/L"] [text size="80" memo="location/size/texture" memo_size="small"];[/conditional][conditional field="GUdetailexamMale" condition="(GUdetailexamMale).is('')"][checkbox name="examGUabnM4" value="INGUINAL HERNIA EXAM-"][/conditional][conditional field="examGUabnM4" condition="(examGUabnM4).is('INGUINAL HERNIA EXAM-')"] palpable inguinal mass with valsalva on [select value="R side|L side|both sides"]
[/conditional][conditional field="GUdetailexam" condition="(GUdetailexam).is('-GU - ')"] [textarea memo="GU free text" memo_size="small" rows="2"]

[/conditional][checkbox name="skindetailexam" memo="*" memo_size="small" value="-Skin - "][conditional field="skindetailexam" condition="(skindetailexam).is('-Skin - ')"][checkbox name="examskin" value="warm|dry|intact|no edema|no erythema|no ecchymosis"]; [comment memo="abnormals" memo_color="orange" memo_size="small"][checkbox name="examskinabn1" value="JAUNDICE|ACROCYANOSIS|DIFFUSE/NON-FOCAL LESION(S)-"][/conditional][conditional field="examskinabn1" condition="(examskinabn1).is('DIFFUSE/NON-FOCAL LESION(S)-')"] LOCATION(S)- [checkbox value="FACE|FOREHEAD|ANTERIOR NECK|POSTERIOR NECK|ANTERIOR TRUNK|POSTERIOR TRUNK|R SHOULDER|L SHOULDER|R ARM|L ARM|R ELBOW|L ELBOW|R FOREARM|L FOREARM|R WRIST|L WRIST|R HAND DORSUM|L HAND DORSUM|R PALM|L PALM|R INGUINAL AREA|L INGUINAL AREA|R HIP|L HIP|R THIGH|L THIGH|R KNEE|L KNEE|R LEG|L LEG|R ANKLE|L ANKLE|R FOOT DORSUM|L FOOT DORSUM|R FOOT SOLE|L FOOT SOLE"]. DESCRIPTION- [checkbox name="examskinabn11" value="MACULAR|PAPULAR|LACEY APPEARANCE|PATCHY|SCATTERED|CLUSTERED|ROUGH TEXTURE|ERYTHEMATOUS|ECCHYMOSIS|SKIN/FLESH COLORED|HYPERPIGMENTED|HYPOPIGMENTED|NON-BLANCHING|SCALY|EXCORIATION|ULCERATION"], [textarea memo="add'l description" memo_color="orange" memo_size="small" rows="2"]
[/conditional][conditional field="skindetailexam" condition="(skindetailexam).is('-Skin - ')"][checkbox name="examskinabn2" value="FOCAL/ISOLATED LESION(S)-"]
[/conditional][conditional field="examskinabn2" condition="(examskinabn2).is('FOCAL/ISOLATED LESION(S)-')"][checkbox memo="1st Lesion" name="Lesion1" value=""][/conditional][conditional field="Lesion1" condition="(Lesion1).is('')"]--Lesion#1
---Location: [select name="skinexamlocation1" value="|Scalp|Face|Neck|Shoulder|Chest/Trunk|Abdomen|Buttocks|Inguinal|Male Genital Region|Female Genital Region|Arm|Elbow|Forearm|Wrist|Hand|Finger|Hip|Thigh|Knee|Leg|Ankle|Foot|Toe"][/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Scalp')"]- [select value="right|left|midline"] [select value="occipital|parietal|temporal|frontal|preauricular|postauricular"] area[/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Face')"]- [select value="right|left|midline"] [select value="preauricular|mandibular angle|cheek|nose|periorbital|perioral|chin|submandibular|submental"] area[/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Neck')"]- [select value="right|left|midline"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Shoulder')||(skinexamlocation1).is('Elbow')||(skinexamlocation1).is('Wrist')||(skinexamlocation1).is('Hip')||(skinexamlocation1).is('Knee')||(skinexamlocation1).is('Ankle')"]- [select value="right|left"], [checkbox value="anterior|posterior|medial|lateral"] aspect[/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Arm')||(skinexamlocation1).is('Forearm')||(skinexamlocation1).is('Thigh')||(skinexamlocation1).is('Leg')"]- [select value="right|left"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Chest/Trunk')"]- [select value="right|left|midline"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Abdomen')"]- [select value="periumbilical|epigastrium|RUQ|LUQ|RLQ|LLQ"] aspect[/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Buttocks')"]- [select value="right|left|midline"] [select value="|medial|lateral"] [select value="perianal|gluteal cleft|cheek|gluteal fold"][/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Inguinal')"]- [select value="right|left"][/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Male Genital Region')"]- [select value="right|left|midline"] [select value="penile glans|penile shaft|base of penis|scrotum|periscrotal area"][/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Female Genital Region')"]- [select value="right|left|midline"] [select value="labia majora|labia minora|perilabial area|periclitoral area|mons pubis|perineum"][/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Hand')||(skinexamlocation1).is('Finger')"]- [select value="right|left"], [checkbox value="palmar/volar|dorsal|medial|lateral"] aspect[/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Finger')"], [select value="1st|2nd|3rd|4th|5th"] digit, [select value="MCP|proximal phalanx|middle phalanx|distal phalanx|periungual area"][/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Foot')||(skinexamlocation1).is('Toe')"]- [select value="right|left"], [checkbox value="plantar|dorsal|medial|lateral"] aspect[/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Toe')"], [select value="1st|2nd|3rd|4th|5th"] digit, [select value="MTP|proximal phalanx|middle phalanx|distal phalanx|periungual area"]
[/conditional][conditional field="Lesion1" condition="(Lesion1).is('')"]---Character/Texture: [checkbox name="skinexamlesion1" value="macule|papule|patch|plaque|rough|smooth|firm|soft|mobile|fixed|pedunculated|palpable subdermal lump|palpable subcutaneous lump"]
---Size: [text size="5"] cm
[/conditional][conditional field="skinexamlesion1" condition="(skinexamlesion1).is('macule')||(skinexamlesion1).is('papule')||(skinexamlesion1).is('patch')||(skinexamlesion1).is('plaque')||(skinexamlesion1).is('rough')||(skinexamlesion1).is('pedunculated')"]---Color: [select value="uniform color|non-uniform color"], [select value="erthythematous|flesh-color|brown|black|blue|multicolored"] [text size="20"]
---Borders: [select value="well-circumscribed|ill-defined"]
[/conditional][conditional field="Lesion1" condition="(Lesion1).is('')"][checkbox value="---Other features:"] [text size="40"]
[/conditional][conditional field="examskinabn2" condition="(examskinabn2).is('FOCAL/ISOLATED LESION(S)-')"][checkbox memo="2nd Lesion" name="Lesion2" value=""][/conditional][conditional field="Lesion2" condition="(Lesion2).is('')"]--Lesion#2
---Location: [select name="skinexamlocation2" value="|Scalp|Face|Neck|Shoulder|Chest/Trunk|Abdomen|Buttocks|Inguinal|Male Genital Region|Female Genital Region|Arm|Elbow|Forearm|Wrist|Hand|Finger|Hip|Thigh|Knee|Leg|Ankle|Foot|Toe"][/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Scalp')"]- [select value="right|left|midline"] [select value="occipital|parietal|temporal|frontal|preauricular|postauricular"] area[/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Face')"]- [select value="right|left|midline"] [select value="preauricular|mandibular angle|cheek|nose|periorbital|perioral|chin|submandibular|submental"] area[/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Neck')"]- [select value="right|left|midline"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Shoulder')||(skinexamlocation2).is('Elbow')||(skinexamlocation2).is('Wrist')||(skinexamlocation2).is('Hip')||(skinexamlocation2).is('Knee')||(skinexamlocation2).is('Ankle')"]- [select value="right|left"], [checkbox value="anterior|posterior|medial|lateral"] aspect[/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Arm')||(skinexamlocation2).is('Forearm')||(skinexamlocation2).is('Thigh')||(skinexamlocation2).is('Leg')"]- [select value="right|left"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Chest/Trunk')"]- [select value="right|left|midline"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Abdomen')"]- [select value="periumbilical|epigastrium|RUQ|LUQ|RLQ|LLQ"] aspect[/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Buttocks')"]- [select value="right|left|midline"] [select value="|medial|lateral"] [select value="perianal|gluteal cleft|cheek|gluteal fold"][/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Inguinal')"]- [select value="right|left"][/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Male Genital Region')"]- [select value="right|left|midline"] [select value="penile glans|penile shaft|base of penis|scrotum|periscrotal area"][/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Female Genital Region')"]- [select value="right|left|midline"] [select value="labia majora|labia minora|perilabial area|periclitoral area|mons pubis|perineum"][/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Hand')||(skinexamlocation2).is('Finger')"]- [select value="right|left"], [checkbox value="palmar/volar|dorsal|medial|lateral"] aspect[/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Finger')"], [select value="1st|2nd|3rd|4th|5th"] digit, [select value="MCP|proximal phalanx|middle phalanx|distal phalanx|periungual area"][/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Foot')||(skinexamlocation2).is('Toe')"]- [select value="right|left"], [checkbox value="plantar|dorsal|medial|lateral"] aspect[/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Toe')"], [select value="1st|2nd|3rd|4th|5th"] digit, [select value="MTP|proximal phalanx|middle phalanx|distal phalanx|periungual area"]
[/conditional][conditional field="Lesion2" condition="(Lesion2).is('')"]---Character/Texture: [checkbox name="skinexamlesion2" value="macule|papule|patch|plaque|rough|smooth|firm|soft|mobile|fixed|pedunculated|palpable subdermal lump|palpable subcutaneous lump"]
---Size: [text size="5"] cm
[/conditional][conditional field="skinexamlesion2" condition="(skinexamlesion2).is('macule')||(skinexamlesion2).is('papule')||(skinexamlesion2).is('patch')||(skinexamlesion2).is('plaque')||(skinexamlesion2).is('rough')||(skinexamlesion2).is('pedunculated')"]---Color: [select value="uniform color|non-uniform color"], [select value="erthythematous|flesh-color|brown|black|blue|multicolored"] [text size="20"]
---Borders: [select value="well-circumscribed|ill-defined"]
[/conditional][conditional field="Lesion2" condition="(Lesion2).is('')"][checkbox value="---Other features:"] [text size="40"]
[/conditional][conditional field="examskinabn2" condition="(examskinabn2).is('FOCAL/ISOLATED LESION(S)-')"][checkbox memo="3rd Lesion" name="Lesion3" value=""][/conditional][conditional field="Lesion3" condition="(Lesion3).is('')"]--Lesion#3
---Location: [select name="skinexamlocation3" value="|Scalp|Face|Neck|Shoulder|Chest/Trunk|Abdomen|Buttocks|Inguinal|Male Genital Region|Female Genital Region|Arm|Elbow|Forearm|Wrist|Hand|Finger|Hip|Thigh|Knee|Leg|Ankle|Foot|Toe"][/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Scalp')"]- [select value="right|left|midline"] [select value="occipital|parietal|temporal|frontal|preauricular|postauricular"] area[/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Face')"]- [select value="right|left|midline"] [select value="preauricular|mandibular angle|cheek|nose|periorbital|perioral|chin|submandibular|submental"] area[/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Neck')"]- [select value="right|left|midline"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Shoulder')||(skinexamlocation3).is('Elbow')||(skinexamlocation3).is('Wrist')||(skinexamlocation3).is('Hip')||(skinexamlocation3).is('Knee')||(skinexamlocation3).is('Ankle')"]- [select value="right|left"], [checkbox value="anterior|posterior|medial|lateral"] aspect[/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Arm')||(skinexamlocation3).is('Forearm')||(skinexamlocation3).is('Thigh')||(skinexamlocation3).is('Leg')"]- [select value="right|left"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Chest/Trunk')"]- [select value="right|left|midline"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Abdomen')"]- [select value="periumbilical|epigastrium|RUQ|LUQ|RLQ|LLQ"] aspect[/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Buttocks')"]- [select value="right|left|midline"] [select value="|medial|lateral"] [select value="perianal|gluteal cleft|cheek|gluteal fold"][/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Inguinal')"]- [select value="right|left"][/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Male Genital Region')"]- [select value="right|left|midline"] [select value="penile glans|penile shaft|base of penis|scrotum|periscrotal area"][/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Female Genital Region')"]- [select value="right|left|midline"] [select value="labia majora|labia minora|perilabial area|periclitoral area|mons pubis|perineum"][/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Hand')||(skinexamlocation3).is('Finger')"]- [select value="right|left"], [checkbox value="palmar/volar|dorsal|medial|lateral"] aspect[/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Finger')"], [select value="1st|2nd|3rd|4th|5th"] digit, [select value="MCP|proximal phalanx|middle phalanx|distal phalanx|periungual area"][/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Foot')||(skinexamlocation3).is('Toe')"]- [select value="right|left"], [checkbox value="plantar|dorsal|medial|lateral"] aspect[/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Toe')"], [select value="1st|2nd|3rd|4th|5th"] digit, [select value="MTP|proximal phalanx|middle phalanx|distal phalanx|periungual area"]
[/conditional][conditional field="Lesion3" condition="(Lesion3).is('')"]---Character/Texture: [checkbox name="skinexamlesion3" value="macule|papule|patch|plaque|rough|smooth|firm|soft|mobile|fixed|pedunculated|palpable subdermal lump|palpable subcutaneous lump"]
---Size: [text size="5"] cm
[/conditional][conditional field="skinexamlesion3" condition="(skinexamlesion3).is('macule')||(skinexamlesion3).is('papule')||(skinexamlesion3).is('patch')||(skinexamlesion3).is('plaque')||(skinexamlesion3).is('rough')||(skinexamlesion3).is('pedunculated')"]---Color: [select value="uniform color|non-uniform color"], [select value="erthythematous|flesh-color|brown|black|blue|multicolored"] [text size="20"]
---Borders: [select value="well-circumscribed|ill-defined"]
[/conditional][conditional field="Lesion3" condition="(Lesion3).is('')"][checkbox value="---Other features:"] [text size="40"]
[/conditional][conditional field="examskinabn2" condition="(examskinabn2).is('FOCAL/ISOLATED LESION(S)-')"][checkbox memo="4th Lesion" name="Lesion4" value=""][/conditional][conditional field="Lesion4" condition="(Lesion4).is('')"]--Lesion#4
---Location: [select name="skinexamlocation4" value="|Scalp|Face|Neck|Shoulder|Chest/Trunk|Abdomen|Buttocks|Inguinal|Male Genital Region|Female Genital Region|Arm|Elbow|Forearm|Wrist|Hand|Finger|Hip|Thigh|Knee|Leg|Ankle|Foot|Toe"][/conditional][conditional field="skinexamlocation4" condition="(skinexamlocation4).is('Scalp')"]- [select value="right|left|midline"] [select value="occipital|parietal|temporal|frontal|preauricular|postauricular"] area[/conditional][conditional field="skinexamlocation4" condition="(skinexamlocation4).is('Face')"]- [select value="right|left|midline"] [select value="preauricular|mandibular angle|cheek|nose|periorbital|perioral|chin|submandibular|submental"] area[/conditional][conditional field="skinexamlocation4" condition="(skinexamlocation4).is('Neck')"]- [select value="right|left|midline"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="skinexamlocation4" condition="(skinexamlocation4).is('Shoulder')||(skinexamlocation4).is('Elbow')||(skinexamlocation4).is('Wrist')||(skinexamlocation4).is('Hip')||(skinexamlocation4).is('Knee')||(skinexamlocation4).is('Ankle')"]- [select value="right|left"], [checkbox value="anterior|posterior|medial|lateral"] aspect[/conditional][conditional field="skinexamlocation4" condition="(skinexamlocation4).is('Arm')||(skinexamlocation4).is('Forearm')||(skinexamlocation4).is('Thigh')||(skinexamlocation4).is('Leg')"]- [select value="right|left"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="skinexamlocation4" condition="(skinexamlocation4).is('Chest/Trunk')"]- [select value="right|left|midline"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="skinexamlocation4" condition="(skinexamlocation4).is('Abdomen')"]- [select value="periumbilical|epigastrium|RUQ|LUQ|RLQ|LLQ"] aspect[/conditional][conditional field="skinexamlocation4" condition="(skinexamlocation4).is('Buttocks')"]- [select value="right|left|midline"] [select value="|medial|lateral"] [select value="perianal|gluteal cleft|cheek|gluteal fold"][/conditional][conditional field="skinexamlocation4" condition="(skinexamlocation4).is('Inguinal')"]- [select value="right|left"][/conditional][conditional field="skinexamlocation4" condition="(skinexamlocation4).is('Male Genital Region')"]- [select value="right|left|midline"] [select value="penile glans|penile shaft|base of penis|scrotum|periscrotal area"][/conditional][conditional field="skinexamlocation4" condition="(skinexamlocation4).is('Female Genital Region')"]- [select value="right|left|midline"] [select value="labia majora|labia minora|perilabial area|periclitoral area|mons pubis|perineum"][/conditional][conditional field="skinexamlocation4" condition="(skinexamlocation4).is('Hand')||(skinexamlocation4).is('Finger')"]- [select value="right|left"], [checkbox value="palmar/volar|dorsal|medial|lateral"] aspect[/conditional][conditional field="skinexamlocation4" condition="(skinexamlocation4).is('Finger')"], [select value="1st|2nd|3rd|4th|5th"] digit, [select value="MCP|proximal phalanx|middle phalanx|distal phalanx|periungual area"][/conditional][conditional field="skinexamlocation4" condition="(skinexamlocation4).is('Foot')||(skinexamlocation4).is('Toe')"]- [select value="right|left"], [checkbox value="plantar|dorsal|medial|lateral"] aspect[/conditional][conditional field="skinexamlocation4" condition="(skinexamlocation4).is('Toe')"], [select value="1st|2nd|3rd|4th|5th"] digit, [select value="MTP|proximal phalanx|middle phalanx|distal phalanx|periungual area"]
[/conditional][conditional field="Lesion4" condition="(Lesion4).is('')"]---Description:
---Character/Texture: [checkbox name="skinexamlesion4" value="macule|papule|patch|plaque|rough|smooth|firm|soft|mobile|fixed|pedunculated|palpable subdermal lump|palpable subcutaneous lump"]
---Size: [text size="5"] cm
[/conditional][conditional field="skinexamlesion4" condition="(skinexamlesion4).is('macule')||(skinexamlesion4).is('papule')||(skinexamlesion4).is('patch')||(skinexamlesion4).is('plaque')||(skinexamlesion4).is('rough')||(skinexamlesion4).is('pedunculated')"]---Color: [select value="uniform color|non-uniform color"], [select value="erthythematous|flesh-color|brown|black|blue|multicolored"] [text size="20"]
---Borders: [select value="well-circumscribed|ill-defined"]
[/conditional][conditional field="Lesion4" condition="(Lesion4).is('')"][checkbox value="---Other features:"] [text size="40"]
[/conditional][conditional field="examskinabn2" condition="(examskinabn2).is('FOCAL/ISOLATED LESION(S)-')"][checkbox memo="5th Lesion" name="Lesion5" value=""][/conditional][conditional field="Lesion5" condition="(Lesion5).is('')"]--Lesion#5
---Location: [select name="skinexamlocation5" value="|Scalp|Face|Neck|Shoulder|Chest/Trunk|Abdomen|Buttocks|Inguinal|Male Genital Region|Female Genital Region|Arm|Elbow|Forearm|Wrist|Hand|Finger|Hip|Thigh|Knee|Leg|Ankle|Foot|Toe"][/conditional][conditional field="skinexamlocation5" condition="(skinexamlocation5).is('Scalp')"]- [select value="right|left|midline"] [select value="occipital|parietal|temporal|frontal|preauricular|postauricular"] area[/conditional][conditional field="skinexamlocation5" condition="(skinexamlocation5).is('Face')"]- [select value="right|left|midline"] [select value="preauricular|mandibular angle|cheek|nose|periorbital|perioral|chin|submandibular|submental"] area[/conditional][conditional field="skinexamlocation5" condition="(skinexamlocation5).is('Neck')"]- [select value="right|left|midline"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="skinexamlocation5" condition="(skinexamlocation5).is('Shoulder')||(skinexamlocation5).is('Elbow')||(skinexamlocation5).is('Wrist')||(skinexamlocation5).is('Hip')||(skinexamlocation5).is('Knee')||(skinexamlocation5).is('Ankle')"]- [select value="right|left"], [checkbox value="anterior|posterior|medial|lateral"] aspect[/conditional][conditional field="skinexamlocation5" condition="(skinexamlocation5).is('Arm')||(skinexamlocation5).is('Forearm')||(skinexamlocation5).is('Thigh')||(skinexamlocation5).is('Leg')"]- [select value="right|left"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="skinexamlocation5" condition="(skinexamlocation5).is('Chest/Trunk')"]- [select value="right|left|midline"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="skinexamlocation5" condition="(skinexamlocation5).is('Abdomen')"]- [select value="periumbilical|epigastrium|RUQ|LUQ|RLQ|LLQ"] aspect[/conditional][conditional field="skinexamlocation5" condition="(skinexamlocation5).is('Buttocks')"]- [select value="right|left|midline"] [select value="|medial|lateral"] [select value="perianal|gluteal cleft|cheek|gluteal fold"][/conditional][conditional field="skinexamlocation5" condition="(skinexamlocation5).is('Inguinal')"]- [select value="right|left"][/conditional][conditional field="skinexamlocation5" condition="(skinexamlocation5).is('Male Genital Region')"]- [select value="right|left|midline"] [select value="penile glans|penile shaft|base of penis|scrotum|periscrotal area"][/conditional][conditional field="skinexamlocation5" condition="(skinexamlocation5).is('Female Genital Region')"]- [select value="right|left|midline"] [select value="labia majora|labia minora|perilabial area|periclitoral area|mons pubis|perineum"][/conditional][conditional field="skinexamlocation5" condition="(skinexamlocation5).is('Hand')||(skinexamlocation5).is('Finger')"]- [select value="right|left"], [checkbox value="palmar/volar|dorsal|medial|lateral"] aspect[/conditional][conditional field="skinexamlocation5" condition="(skinexamlocation5).is('Finger')"], [select value="1st|2nd|3rd|4th|5th"] digit, [select value="MCP|proximal phalanx|middle phalanx|distal phalanx|periungual area"][/conditional][conditional field="skinexamlocation5" condition="(skinexamlocation5).is('Foot')||(skinexamlocation5).is('Toe')"]- [select value="right|left"], [checkbox value="plantar|dorsal|medial|lateral"] aspect[/conditional][conditional field="skinexamlocation5" condition="(skinexamlocation5).is('Toe')"], [select value="1st|2nd|3rd|4th|5th"] digit, [select value="MTP|proximal phalanx|middle phalanx|distal phalanx|periungual area"]
[/conditional][conditional field="Lesion5" condition="(Lesion5).is('')"]---Character/Texture: [checkbox name="skinexamlesion5" value="macule|papule|patch|plaque|rough|smooth|firm|soft|mobile|fixed|pedunculated|palpable subdermal lump|palpable subcutaneous lump"]
---Size: [text size="5"] cm
[/conditional][conditional field="skinexamlesion5" condition="(skinexamlesion5).is('macule')||(skinexamlesion5).is('papule')||(skinexamlesion5).is('patch')||(skinexamlesion5).is('plaque')||(skinexamlesion5).is('rough')||(skinexamlesion5).is('pedunculated')"]---Color: [select value="uniform color|non-uniform color"], [select value="erthythematous|flesh-color|brown|black|blue|multicolored"] [text size="20"]
---Borders: [select value="well-circumscribed|ill-defined"]
[/conditional][conditional field="Lesion5" condition="(Lesion5).is('')"][checkbox value="---Other features:"] [text size="40"]
[/conditional][conditional field="skindetailexam" condition="(skindetailexam).is('-Skin - ')"] [textarea memo="Skin freetext" memo_size="small" rows="2"]

[/conditional][checkbox name="MSKdetailexam" memo="*" memo_size="small" value="-MSK - "][conditional field="MSKdetailexam" condition="(MSKdetailexam).is('-MSK - ')"][checkbox value="no gross deformities noted|No joint erythema|No tenderness|Normal tone|Normal muscular development|Normal gait"]; [textarea memo="MSK freetext" memo_size="small" rows="2"]

[/conditional][checkbox name="EXTdetailexam" memo="*" memo_size="small" value="-EXT - "][conditional field="EXTdetailexam" condition="(EXTdetailexam).is('-EXT - ')"][checkbox value="no gross deformities noted|no cyanosis|no clubbing|peripheral pulses 2/4 x4"]; [comment memo="abnormals" memo_color="orange" memo_size="small"][checkbox name="examEXTabn1" value="CLUBBING-"][/conditional][conditional field="examEXTabn1" condition="(examEXTabn1).is('CLUBBING-')"] [checkbox value="DIGITS UPPER EXTREMITY|GROSS DEFORMITY"] [text size="80"];[/conditional][conditional field="EXTdetailexam" condition="(EXTdetailexam).is('-EXT - ')"] [textarea memo="Extremities freetext" memo_size="small" rows="2"]

[/conditional][checkbox name="NEUROdetailexam" memo="*" memo_size="small" value="-Neuro - "][conditional field="NEUROdetailexam" condition="(NEUROdetailexam).is('-Neuro - ')"][checkbox value="mentating well|moves all extremities equally well|CN 2-12 grossly intact b/l|normal sensorium all 4 extremities|no gross motor deficits|Romberg negative|cerebellar testing normal|DTRs 2/4 x4|gait testing without abnormalities"]; [comment memo="abnormals" memo_color="orange" memo_size="small"][checkbox name="examNEUROabn1" value="SENSORY DEFICIT(S)- "][/conditional][conditional field="examNEUROabn1" condition="(examNEUROabn1).is('SENSORY DEFICIT(S)- ')"][checkbox name="examNEUROabn11" value="Scalp "][/conditional][conditional field="examNEUROabn11" condition="(examNEUROabn11).is('Scalp ')"][checkbox value="R occipital|R parietal|R temporal|R frontal|R preauricular|R postauricular|L occipital|L parietal|L temporal|L frontal|L preauricular|L postauricular"] area(s) [textarea rows="2" memo="description if needed"memo_size="small"]; [/conditional][conditional field="examNEUROabn1" condition="(examNEUROabn1).is('SENSORY DEFICIT(S)- ')"][checkbox name="examNEUROabn12" value="Face "][/conditional][conditional field="examNEUROabn12" condition="(examNEUROabn12).is('Face ')"][checkbox value="R preauricular|R mandibular angle|R cheek|R nasal bridge|R periorbital|R perioral|chin|submental|R submandibular|L preauricular|L mandibular angle|L cheek|L nasal bridge|L periorbital|L perioral|L submandibular"] area(s) [textarea rows="2" memo="description if needed"memo_size="small"]; [/conditional][conditional field="examNEUROabn1" condition="(examNEUROabn1).is('SENSORY DEFICIT(S)- ')"][checkbox name="examNEUROabn13" value="Neck "][/conditional][conditional field="examNEUROabn13" condition="(examNEUROabn13).is('Neck ')"][select value="right|left"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect(s) [textarea rows="2" memo="description if needed" memo_size="small"]; [/conditional][conditional field="examNEUROabn1" condition="(examNEUROabn1).is('SENSORY DEFICIT(S)- ')"][checkbox name="examNEUROabn14" value="Shoulder "][/conditional][conditional field="examNEUROabn14" condition="(examNEUROabn14).is('Shoulder ')"][checkbox value="right|left|anterior|posterior|medial|lateral"] aspect(s) [textarea rows="2" memo="description if needed"memo_size="small"]; [/conditional][conditional field="examNEUROabn1" condition="(examNEUROabn1).is('SENSORY DEFICIT(S)- ')"][checkbox name="examNEUROabn15" value="Chest/Trunk "][/conditional][conditional field="examNEUROabn15" condition="(examNEUROabn15).is('Chest/Trunk ')"][select value="right|left|midline"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior"] aspect(s) [textarea rows="2" memo="description if needed"memo_size="small"]; [/conditional][conditional field="examNEUROabn1" condition="(examNEUROabn1).is('SENSORY DEFICIT(S)- ')"][checkbox name="examNEUROabn16" value="Abdomen "][/conditional][conditional field="examNEUROabn16" condition="(examNEUROabn16).is('Abdomen ')"][checkbox value="periumbilical|epigastrium|RUQ|LUQ|RLQ|LLQ"] aspect(s) [textarea rows="2" memo="description if needed"memo_size="small"]; [/conditional][conditional field="examNEUROabn1" condition="(examNEUROabn1).is('SENSORY DEFICIT(S)- ')"][checkbox name="examNEUROabn17" value="Buttocks "][/conditional][conditional field="examNEUROabn17" condition="(examNEUROabn17).is('Buttocks ')"][checkbox value="right|left|midline|medial|lateral|perianal|gluteal cleft|cheek|gluteal fold|saddle"] aspect(s) [textarea rows="2" memo="description if needed"memo_size="small"]; [/conditional][conditional field="examNEUROabn1" condition="(examNEUROabn1).is('SENSORY DEFICIT(S)- ')"][checkbox name="examNEUROabn18" value="Inguinal "][/conditional][conditional field="examNEUROabn18" condition="(examNEUROabn18).is('Inguinal ')"][checkbox value="right|left|superior|inferior|medial|lateral"] aspect(s) [textarea rows="2" memo="description if needed"memo_size="small"]; [/conditional][conditional field="examNEUROabn1" condition="(examNEUROabn1).is('SENSORY DEFICIT(S)- ')"][checkbox name="examNEUROabn19" value="Male Genital "][/conditional][conditional field="examNEUROabn19" condition="(examNEUROabn19).is('Male Genital ')"][checkbox value="right|left|midline|b/l|penile glans|penile shaft|base of penis|scrotum|periscrotal"] aspect(s) [textarea rows="2" memo="description if needed"memo_size="small"]; [/conditional][conditional field="examNEUROabn1" condition="(examNEUROabn1).is('SENSORY DEFICIT(S)- ')"][checkbox name="examNEUROabn111" value="Female Genital "][/conditional][conditional field="examNEUROabn111" condition="(examNEUROabn111).is('Female Genital ')"][checkbox value="right|left|midline|labia majora|labia minora|perilabial area|periclitoral area|mons pubis|perineum"] aspect(s) [textarea rows="2" memo="description if needed"memo_size="small"]; [/conditional][conditional field="examNEUROabn1" condition="(examNEUROabn1).is('SENSORY DEFICIT(S)- ')"][checkbox name="examNEUROabn112" value="Arm "][/conditional][conditional field="examNEUROabn112" condition="(examNEUROabn112).is('Arm ')"][checkbox value="right|left|anterior|posterior|medial|lateral|superior|inferior|middle"] aspect(s) [textarea rows="2" memo="description if needed"memo_size="small"]; [/conditional][conditional field="examNEUROabn1" condition="(examNEUROabn1).is('SENSORY DEFICIT(S)- ')"][checkbox name="examNEUROabn113" value="Elbow "][/conditional][conditional field="examNEUROabn113" condition="(examNEUROabn113).is('Elbow ')"][checkbox value="right|left|anterior|posterior|medial|lateral|antecubital|olecranon|epicondylar"] aspect(s) [textarea rows="2" memo="description if needed" memo_size="small"]; [/conditional][conditional field="examNEUROabn1" condition="(examNEUROabn1).is('SENSORY DEFICIT(S)- ')"][checkbox name="examNEUROabn114" value="Forearm "][/conditional][conditional field="examNEUROabn114" condition="(examNEUROabn114).is('Forearm ')"][checkbox value="right|left|anterior|posterior|medial|lateral|distal|proximal"] aspect(s) [textarea rows="2" memo="description if needed"memo_size="small"]; [/conditional][conditional field="examNEUROabn1" condition="(examNEUROabn1).is('SENSORY DEFICIT(S)- ')"][checkbox name="examNEUROabn115" value="Wrist "][/conditional][conditional field="examNEUROabn115" condition="(examNEUROabn115).is('Wrist ')"][checkbox value="right|left|anterior|posterior|volar|dorsal|medial|lateral"] aspect(s) [textarea rows="2" memo="description if needed"memo_size="small"]; [/conditional][conditional field="examNEUROabn1" condition="(examNEUROabn1).is('SENSORY DEFICIT(S)- ')"][checkbox name="examNEUROabn116" value="Hand/Finger(s) "][/conditional][conditional field="examNEUROabn116" condition="(examNEUROabn116).is('Hand/Finger(s) ')"][checkbox value="right|left|palmar/volar hand|dorsal hand|medial|lateral|thenar|hypothenar|1st digit|2nd digit|3rd digit|4th digit|5th digit|MCP|proximal phalanx|middle phalanx|distal phalanx|periungual|dorsal|volar|medial|lateral"]aspect(s) [textarea rows="2" memo="description if needed"memo_size="small"]; [/conditional][conditional field="examNEUROabn1" condition="(examNEUROabn1).is('SENSORY DEFICIT(S)- ')"][checkbox name="examNEUROabn117" value="Hip "][/conditional][conditional field="examNEUROabn117" condition="(examNEUROabn117).is('Hip ')"][checkbox value="right|left|anterior|posterior|medial|lateral"] aspect(s) [textarea rows="2" memo="description if needed"memo_size="small"]; [/conditional][conditional field="examNEUROabn1" condition="(examNEUROabn1).is('SENSORY DEFICIT(S)- ')"][checkbox name="examNEUROabn118" value="Thigh "][/conditional][conditional field="examNEUROabn118" condition="(examNEUROabn118).is('Thigh ')"][checkbox value="right|left|anterior|posterior|medial|lateral|superior|inferior|middle"] aspect(s) [textarea rows="2" memo="description if needed"memo_size="small"]; [/conditional][conditional field="examNEUROabn1" condition="(examNEUROabn1).is('SENSORY DEFICIT(S)- ')"][checkbox name="examNEUROabn119" value="Knee "][/conditional][conditional field="examNEUROabn119" condition="(examNEUROabn119).is('Knee ')"][checkbox value="right|left|anterior|posterior|medial|lateral"] aspect(s) [textarea rows="2" memo="description if needed"memo_size="small"]; [/conditional][conditional field="examNEUROabn1" condition="(examNEUROabn1).is('SENSORY DEFICIT(S)- ')"][checkbox name="examNEUROabn120" value="Leg "][/conditional][conditional field="examNEUROabn120" condition="(examNEUROabn120).is('Leg ')"][checkbox value="right|left|anterior|posterior|medial|lateral|superior|inferior|middle"] aspect(s) [textarea rows="2" memo="description if needed"memo_size="small"]; [/conditional][conditional field="examNEUROabn1" condition="(examNEUROabn1).is('SENSORY DEFICIT(S)- ')"][checkbox name="examNEUROabn121" value="Ankle "][/conditional][conditional field="examNEUROabn121" condition="(examNEUROabn121).is('Ankle ')"][checkbox value="right|left|anterior|posterior|medial|lateral"] aspect(s) [textarea rows="2" memo="description if needed"memo_size="small"]; [/conditional][conditional field="examNEUROabn1" condition="(examNEUROabn1).is('SENSORY DEFICIT(S)- ')"][checkbox name="examNEUROabn122" value="Foot/Toe(s) "][/conditional][conditional field="examNEUROabn122" condition="(examNEUROabn122).is('Foot/Toe(s) ')"][checkbox value="right|left|plantar|dorsal|medial|lateral|distal|proximal|1st digit|2nd digit|3rd digit|4th digit|5th digit|MTP|proximal phalanx|middle phalanx|distal phalanx|periungual area"] aspect(s) [textarea rows="2" memo="description of deficit" memo_size="small" memo_color="orange"]; [/conditional][conditional field="NEUROdetailexam" condition="(NEUROdetailexam).is('-Neuro - ')"][checkbox name="examNEUROabn2" value="MOTOR DEFICIT(S)- "][/conditional][conditional field="examNEUROabn2" condition="(examNEUROabn2).is('MOTOR DEFICIT(S)- ')"][checkbox name="examNEUROabn21" value="R UPPER EXTREMITY- "][/conditional][conditional field="examNEUROabn21" condition="(examNEUROabn21).is('R UPPER EXTREMITY')"]STRENGTH [text size="5"]/5; [/conditional][conditional field="examNEUROabn2" condition="(examNEUROabn2).is('MOTOR DEFICIT(S)- ')"][checkbox name="examNEUROabn22" value="L UPPER EXTREMITY- "][/conditional][conditional field="examNEUROabn22" condition="(examNEUROabn22).is('L UPPER EXTREMITY')"]STRENGTH [text size="5"]/5; [/conditional][conditional field="examNEUROabn2" condition="(examNEUROabn2).is('MOTOR DEFICIT(S)- ')"][checkbox name="examNEUROabn23" value="R LOWER EXTREMITY- "][/conditional][conditional field="examNEUROabn23" condition="(examNEUROabn23).is('R LOWER EXTREMITY- ')"]STRENGTH [text size="5"]/5; [/conditional][conditional field="examNEUROabn2" condition="(examNEUROabn2).is('MOTOR DEFICIT(S)- ')"]--[checkbox name="examNEUROabn24" value="L LOWER EXTREMITY- "][/conditional][conditional field="examNEUROabn24" condition="(examNEUROabn24).is('L LOWER EXTREMITY- ')"]STRENGTH [text size="5"]/5; [/conditional][conditional field="examNEUROabn2" condition="(examNEUROabn2).is('MOTOR DEFICIT(S)- ')"][text memo="motor deficit freetext" memo_size="small" size="80"]; [/conditional][conditional field="NEUROdetailexam" condition="(NEUROdetailexam).is('-Neuro - ')"][checkbox name="examNEUROabn3" value="ABNORMAL REFLEXES- "][/conditional][conditional field="examNEUROabn3" condition="(examNEUROabn3).is('ABNORMAL REFLEXES- ')"][checkbox value="BICEPS|TRICEPS|BRACIORADIALIS|PATELLAR|ACHILLES"] [text memo="abn reflexes freetext" memo_size="small" size="80"]; [/conditional][conditional field="NEUROdetailexam" condition="(NEUROdetailexam).is('-Neuro - ')"][checkbox name="examNEUROabn4" value="CEREBELLAR DEFICITS- "][/conditional][conditional field="examNEUROabn4" condition="(examNEUROabn4).is('CEREBELLAR DEFICITS- ')"][checkbox value="POSITIVE ROMBERG|PRONATOR DRIFT|IMPAIRED FINGER-TO-NOSE|IMPAIRED HAND PRONATE/SUPINATE|IMPARIED HEEL-TO-SHIN"] [text memo="cerebellar deficits freetext" memo_size="small" size="80"]; [/conditional][conditional field="NEUROdetailexam" condition="(NEUROdetailexam).is('-Neuro - ')"][checkbox name="examNEUROabn5" value="GAIT- "][/conditional][conditional field="examNEUROabn5" condition="(examNEUROabn5).is('GAIT- ')"][checkbox value="HEMIPLEGIC|DIPLEGIC|NEUROPATHIC|CHOREIFORM|ATAXIC|PARKINSONIAN"] [text memo="abn gait freetext" memo_size="small" size="80"]; [/conditional][conditional field="NEUROdetailexam" condition="(NEUROdetailexam).is('-Neuro - ')"] [textarea memo="Neuro Freetext" memo_size="small" rows="2"][/conditional]

[checkbox name="PSYCHdetailexam" memo="*" memo_size="small" value="-PSYCH - "][conditional field="PSYCHdetailexam" condition="(PSYCHdetailexam).is('-PSYCH - ')"]Mental Status Exam:

[textarea default="Appearance: General appearance of the pt, including apparent age, height, weight and manner of dress and grooming. e.g. disheveled, proper/poor hygiene, appears (older/younger) than stated age."]
[textarea default="Behavior: observations of specific abnormal movements, as well as more general observations of the pts level of activity and arousal, and observations of the pts eye contact and gait. eg uncooperative with exam, proper/poor eye contact, proper/poor engagement, repetitive movements."]
[textarea default="Hygiene: How do they appear? Body odor and grooming?"]
[textarea default="Motor: Psychiatric disturbances manifesting in changes/deficiencies in motor function. Eg psychomotor agitation, psychomotor impairment, tremors, restlessness."]
[textarea default="Psychomotor Agitation and Retardation: Both absent No tremors or tics were observed. No hypokinesia, EPS or TD present."]
[textarea default="Rate of Speech: "]
[textarea default="Rhythm of Speech: "]
[textarea default="Speech Volume: "]
[textarea default="Mood: Description of pts internal emotional state in their own words. Eg happy, sad, ok, good, great, depressed."]  
[textarea default="Affect: Description of pts apparent emotions conveyed by the pts nonverbal behavior (anxious, sad, etc.) and also by using the parameters of appropriateness, intensity, range, reactivity and mobility. Eg affect - neutral, euthymic, dysphoric, euphoric, angry, anxious, apathetic, irritable, guarded, inappropriate. range - flat, blunted, restricted/constricted, full/normal, labile/expansive. Congruence with reported mood? "]
[textarea default="Thought Processes: Description of quantity, tempo (rate of flow) and form (or logical coherence) of thought. Eg linear, logical, goal directed, disorganized, flight of ideas, tangential, circumferential."]
[textarea default="Thought Content: Description of a patients delusions, overvaulted ideas, obsessions, phobias, and preoccupations. eg thoughts endorsing or denying suicidal ideations, homicidal ideations, paranoid ideations, ideas of reference, any fixations or preoccupations."]
[textarea default="Homicidal Ideation: "]
[textarea default="Suicidal Ideation: "]
[textarea default="Delusions: "]
[textarea default="Paranoia: "]
[textarea default="Perceptual Disturbances: Description of disruption in one's organization, identification, or interpretation of sensory information. Eg auditory, visual hallucinations and illusions, other internal stimuli."]
[textarea default="Auditory Hallucinations: Denies."]
[textarea default="Visual Hallucinations: Denies. There does not appear to be any internal stimulation during the course of the evaluation."]
[textarea default="Illusions: Denies."]
[textarea default="Orientation: Alert and oriented to person, place, time, and situation."]
[textarea default="Memory: Immediate, short term, long term, fund of knowledge. Remembering words etc."]
[textarea default="Concentration: Ability to concentrate with serial sevens or spelling world backward."]
[textarea default="Attention: Ability to spell world forward."]
[textarea default="Abstract Reasoning: Ability to understand and think with complex concepts that, while real, are not tied to concrete experiences, objects, people, or situations."]
[textarea default="Impulsivity: Fair."]
[textarea default="Reliability: Fair."]
[textarea default="Insight: Understanding of pts mental illness/disease process. Evaluated by exploring pts explanatory account of the problem and available treatment options. Eg poor, good, fair"]
[textarea default="Judgement: Pts capacity to make sound, reasoned and responsible decisions."][/conditional]

[checkbox name="MasterLI" memo="Labs and Imaging" memo_size="large" value=""][conditional field="MasterLI" condition="(MasterLI).is('')"]

Labs and Imaging:

[textarea name="FreeTextLI" default="Free text any labs and Imaging findings"]

-BMP and CBC

BMP Male 
[text name="variable_1111" default=0mEq/L size=10] <-- Na (normal: [text name="variable_2" default=136mEq/L size=10] to [text name="variable_3" default=145mEq/L size=10])
[text name="variable_4" default=0mEq/L size=10] <-- K (normal: [text name="variable_5" default=3.5mEq/L size=10] to [text name="variable_6" default=5.0mEq/L size=10])
[text name="variable_7" default=0mEq/L size=10] <-- Cl (normal: [text name="variable_8" default=98mEq/L size=10] to [text name="variable_9" default=106mEq/L size=10])
[text name="variable_10" default=0mEq/L size=10] <-- CO2 aka Bicarbonate (normal: [text name="variable_11" default=23mEq/L size=10] to [text name="variable_12" default=28mEq/L size=10])
[text name="variable_13" default=0mg/dL size=10] <-- BUN (normal: [text name="variable_14" default=8mg/dL size=10] to [text name="variable_15" default=20mg/dL size=10])
[text name="variable_16" default=0mg/dL size=10] <-- Cr (normal: [text name="variable_17" default=0.70mg/dL size=10] to [text name="variable_18" default=1.30mg/dL size=10])
[text name="variable_19" default=0mg/dL size=10] <-- Glu (normal: [text name="variable_20" default=65mg/dL size=10] to [text name="variable_21" default=139mg/dL size=10])
[text name="variable_199" default=0mg/dL size=10] <-- Ca (normal: [text name="variable_200" default=8.6mg/dL size=10] to [text name="variable_211" default=10.2mg/dL size=10])

CBC Male Shortened
[text name="variable_22" default=0k/μL size=10] <-- WBC (normal: [text name="variable_23" default=4.0k/μL size=10] to [text name="variable_24" default=11.0k/μL size=10])
[text name="variable_25" default=0g/dL size=10] <-- Hb (normal: [text name="variable_26" default=14g/dL size=10] to [text name="variable_27" default=18g/dL size=10])
[text name="variable_28" default=0% size=10] <-- Hct (normal: [text name="variable_29" default=42% size=10] to [text name="variable_30" default=50% size=10])
[text name="variable_31" default=0k/μL size=10] <-- Plt (normal: [text name="variable_32" default=150k/μL size=10] to [text name="variable_33" default=450k/μL size=10])

BMP Female 
[text name="variable_34" default=0mEq/L size=10] <-- Na (normal: [text name="variable_35" default=136mEq/L size=10] to [text name="variable_36" default=145mEq/L size=10])
[text name="variable_37" default=0mEq/L size=10] <-- K (normal: [text name="variable_38" default=3.5mEq/L size=10] to [text name="variable_39" default=5.0mEq/L size=10])
[text name="variable_40" default=0mEq/L size=10] <-- Cl (normal: [text name="variable_41" default=98mEq/L size=10] to [text name="variable_42" default=106mEq/L size=10])
[text name="variable_43" default=0mEq/L size=10] <-- CO2 aka Bicarbonate (normal: [text name="variable_44" default=23mEq/L size=10] to [text name="variable_45" default=28mEq/L size=10])
[text name="variable_46" default=0mg/dL size=10] <-- BUN (normal: [text name="variable_47" default=8mg/dL size=10] to [text name="variable_48" default=20mg/dL size=10])
[text name="variable_49" default=0mg/dL size=10] <-- Cr (normal: [text name="variable_50" default=0.50mg/dL size=10] to [text name="variable_51" default=1.10mg/dL size=10])
[text name="variable_52" default=0mg/dL size=10] <-- Glu (normal: [text name="variable_53" default=65mg/dL size=10] to [text name="variable_54" default=139mg/dL size=10])
[text name="variable_1999" default=0mg/dL size=10] <-- Ca (normal: [text name="variable_2000" default=8.6mg/dL size=10] to [text name="variable_2111" default=10.2mg/dL size=10])

CBC Female Shortened
[text name="variable_55" default=0k/μL size=10] <-- WBC (normal: [text name="variable_56" default=4.0k/μL size=10] to [text name="variable_57" default=11.0k/μL size=10])
[text name="variable_58" default=0g/dL size=10] <-- Hb (normal: [text name="variable_59" default=12g/dL size=10] to [text name="variable_60" default=16g/dL size=10])
[text name="variable_61" default=0% size=10] <-- Hct (normal: [text name="variable_62" default=37% size=10] to [text name="variable_63" default=47% size=10])
[text name="variable_64" default=0k/μL size=10] <-- Plt (normal: [text name="variable_65" default=150k/μL size=10] to [text name="variable_66" default=450k/μL size=10])

[/conditional]

[checkbox memo="CBC and CMP References (Hide/Show)" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"][link memo="American Board of Internal Medicine laboratory test reference ranges." url="https://www.abim.org/~/media/ABIM%20Public/Files/pdf/exam/laboratory-reference-ranges.pdf"][/conditional]

[checkbox name="MasterAP" memo="A+P" memo_size="large" value=""][conditional field="MasterAP" condition="(MasterAP).is('')"]

Assessment and Plan:

[textarea cols=80 rows=2 default="#1 Problem"]
[textarea cols=80 rows=2 default="#2 Problem"]
[textarea cols=80 rows=2 default="#3 Problem"]
[textarea cols=80 rows=2 default="#4+ Problem"]

[/conditional]
Date and Time of Service:

Chief Complaints:


History of Present Illness:


Past Medical History:


Medications:


Allergies and Medication Intolerances:


Past Surgical History:


Past Hospitalizations and ER Visits:


Preventive Care Services/Care Gaps/Vaccinations:


Social History:

-Diet:

-Exercise:

-Drug Usage:

-Tobacco Usage:

-Alcohol Usage:

-Caffeine Usage:

-Occupation:

-Sex History:


Family History:


Advance Directives:


ROS

Physical Exam:



Chaperone

Additional Individuals Present During History and Physical

Vitals

Brief Visual Exam * * * * * * * * ; * * * *

*

Labs and Imaging

CBC and CMP References (Hide/Show)

A+P

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