General & Administrative
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[text name="name" default="Name"]
[text name="Age" default="Age"]
[text name="Race" default="Race"]
[text name="Gender" default="Gender"]
[date name="Date" default="Date"]
[checkbox name="General" value="Alert|Not in distress|Well-groomed|Disheveled|Distressed|In respiratory distress|Relaxed|Thin|Obese|Energetic|Lethargic"]
Chief Complaint:
[text name="variable_1" default="sample text"]
Source: [select name="Source" value="Self|Other"]
Reliability: [select name="Reliability" value="Reliable|Other"]

History of Present Illness: [textarea name="HPI" memo="HPI" default="Onset:\nLocation: \nDuration: \nCharacteristics:\nAggravating:\nAlleviating/Relieving:\nTreatments Tried:\n\n\n"]

Review of Systems:
General: [checklist name="General" value="Weight Loss|Fever|Chills|Sweats|Anorexia|Fatigue|Malaise"]
Skin: [checklist name="Skin" value="Rashes|Lesions|Itching|Dryness|Sweating"]
HEENT:
Head: [checklist name="Head" value="Headache|Head Trauma|Hair Loss"]
Eyes: [checklist name="Eyes" value="Glasses|Eye Discomfort|Eye Discharge|Photophobia |"]
Ears: [checklist name="Ears" value="Earache|Ear Discharge|Vertigo|Hearing Problems|Tinnitus"]
Nose: [checklist name="Nose" value="Congestion|Nosebleeds"]
Throat: [checklist name="Throat" value="Sore Throat|Hoarseness|Dysphagia|Odynophagia"]
Neck: [checklist name="Neck" value="Neck Lumps|Neck Pain"]
Breast: [checklist name="Breast" value="Breast Pain|Nipple Discharge"]
Respiratory: [checklist name="Respiratory" value="Cough|Sputum|Hemoptysis|Dyspnea|Wheezing"]
Cardiovascular: [checklist name="Cardiovascular" value="Chest Discomfort|Palpitations|Dyspnea|Orthopnea|PND|Syncope|Edema"]
Gastrointestinal: [checklist name="Gastrointestinal" value="Abdominal Pain|Nausea|Vomiting|Diarrhea|Constipation|Bowel Habit Changes|Jaundice|Vomiting Blood|Blood in Stool |Tarry Stools"]
Genitourinary: [checklist name="Genitourinary" value="Painful Urination|GU Discharge|Hematuria|Flank Pain |Frequent Urination|Nocturia|Incontinence|Hesitancy|Difficulty Urinating"]
Male Genital: [checklist name="Male Genital" value="Testicular Pain|Testicular Lumps|Genital Pain|Genital Lesions"]
Female Genital: [checklist name="Female Genital" value="Amenorrhea|Dysmenorrhea|Menorrhagia|Vaginal Bleeding|Pelvic Pain|Genital Pain|Genital Lesions"]
Musculoskeletal: [checklist name="Musculoskeletal" value="Back Pain|Joint Pain|Joint Swelling|Muscle Pain|Muscle Weakness|Stiffness"]
Psychiatric: [checklist name="Psychiatric" value="Depression|Anxiety|Suicidal Ideation|Homicidal Ideation|Memory Loss|Mental Disturbances|Hallucinations|Paranoia"]
Neurologic: [checklist name="Neurologic" value="Weakness|Paresis|Paralysis|Numbness/Tingling|Sensory Loss|Tremors|Seizures|Syncope|Dizziness|Memory Loss|"]
Hematologic: [checklist name="Hematologic" value="Easy Bruising|Easy Bleeding|Lymphadenopathy|"]
Endocrine: [checklist name="Endocrine" value="Cold Intolerance|Heat Intolerance|Sweating|Excessive Thirst|Excessive Hunger|Excessive Urination|Weight Changes"]

Past Medical History: [textarea name="Past Medical History" memo="PMH" default="Similar Occurrences in the Past: \nCurrent Conditions:\nPast Hospitalizations:\nPast Surgeries:\nChildhood Illnesses:\nPsychiatric:\nImmunizations: \nOB/GYN: \n"]

Family History: [textarea name="Family History" memo="Family" default="Parents:\nSiblings:\nChildren:\nOther:"]

Social History: [textarea name="Social History" memo="Social" default="Smoking/Tobacco Use:\nAlcohol:\nIllicit Drugs:\nWork:\nHome:\nRelationships:\nSexual Activity:\nDiet:\nExercise:\nReligion/Beliefs:\nEducation:"]

Medications: [text name="Medications" memo="Medications" size="5"]

Allergies: [text name="Allergies" memo="Allergies" size="5"]

Vitals: [textarea name="Vitals" memo="Vitals" default="Height: \nWeight:\nBody Fat %:\nMuscle %:\nVisceral Fat %: \nBMI: \nBlood Pressure:\nHeart Rate:\nRespiratory Rate:\nTemperature:\nO2 Sat:"]

Physical Exam:
Skin: [checklist name="Skin Color" value="Pink|Appropriate for Race|Abnormal"]
[checklist name="Skin Feel" value="Warm and Dry|Diaphoretic|Clammy|Cool|Abnormal"]
[checklist name="Appearance" value="No rashes or lesions|Rash|Lesion|Erythema|Vesicle|Patch|No red streaking|No warmth to touch|No purulent discharge/drainage|Purulent discharge|Tender to palpation"]
Nails: [checklist name="Nails" value="No clubbing or cyanosis|Clubbing|Cyanosis"]

HEENT:
Head: [checklist name="Head" value="Normocephalic/Atraumatic|Average hair texture"]
Eyes:






Chief Complaint:

Source:
Reliability:

History of Present Illness: HPI

Review of Systems:
General:
Skin:
HEENT:
Head:
Eyes:
Ears:
Nose:
Throat:
Neck:
Breast:
Respiratory:
Cardiovascular:
Gastrointestinal:
Genitourinary:
Male Genital:
Female Genital:
Musculoskeletal:
Psychiatric:
Neurologic:
Hematologic:
Endocrine:

Past Medical History: PMH

Family History: Family

Social History: Social

Medications: Medications

Allergies: Allergies

Vitals: Vitals

Physical Exam:
Skin:


Nails:

HEENT:
Head:
Eyes:

Result - Copy and paste this output: