Geriatric Visit

Date: [date name="date"] 
Patient name:[text]
Age: [text]
DOB: [text]
Gender: [select name="Gender" value="Select|Male|Female|M2F|F2M|I/GQ"]
History provided by: [checkbox value="patient|spouse|adult child|nurse/caretaker"][text]

CC: [checkbox value="chronic condition management|medication alteration follow-up|annual physical|new patient, establishing care"][textarea]

Date began: [text] 
Position: [textarea]
Quality: [textarea] [textarea name="quality" default="Patient's pain began at ******/10 on the pain scale. At its worst it was a ******/10. It is currently a ******/10." fillable="true"]
Remitting factors: [textarea] 
Relieving factors: [textarea]
Associated Symptoms: [textarea]
Symptoms are now: [checkbox value="the same|worsening|getting better"]
Timing/Setting: [textarea]

Childhood Illnesses: [checkbox value="chicken pox|rubella|measles|mumps|polio|asthma"][textarea]
Adult Illnesses: [checkbox value="hypertension|type 2 diabetes|hypercholesterolemia|hypothyroidism|BPH|AFib|CHF|asthma|COPD|sleep apnea|renal disease|coronary artery disease"][textarea]
Surgeries: [textarea]
Other Hospitalizations: [textarea]
Accidents/Injuries: [textarea] 
OB/Gyn: [textarea name="ob-gyn" default="Menarche age ****** yrs.; cycle length ****** days; period length ****** days; G: ****** P: ****** A: ****** ; menopause age ****** yrs." fillable="true"]
Psych: [textarea]

Immunizations: [checkbox value="up to date according to office records|vaccine status unknown|due for seasonal flu vaccine"]
Screenings: [textarea]

Allergies: [text default="NKDA. No known food or environmental allergies."]
Alternative med: [text default="none"]
Travel:[textarea default="no recent travel outside of U.S."]

Father:[checkbox value="alive|deceased"][checkbox value="no known medical conditions"] age[text]yrs. [text]
Mother:[checkbox value="alive|deceased"][checkbox value="no known medical conditions"] age[text]yrs. [text]
Brothers: [textarea default="none"]
Sisters: [textarea default="none"]
Children: [textarea default="none"]
Admits FamHX of:[checkbox value="diabetes|heart disease|hypertension|stroke|cancer|bleeding disorders|asthma|arthritis |TB|epilepsy|mental illness|symptoms of presenting illness"][text]
Denies FamHx of:[checkbox value="diabetes|heart disease|hypertension|stroke|cancer|bleeding disorders|asthma|arthritis |TB|epilepsy|mental illness|symptoms of presenting illness"][text]

Marital Status: [select value="select|single|married|divorced|widowed"]
Occupation: [text]
Living arrangements: [textarea name="living" default="Patient lives with ***text***" fillable="true"]
Nutrition: [checkbox value="eats a balanced diet|eats a high fat diet|eats a high carb diet|eats sweets|vegetarian|vegan"][text]
Exercise: [text]
Religion: [checkbox value="none|Protestant|Catholic|Jewish|Buddhist|Muslim|Hindu"] [text]
Cigarette smoking: [text area default="patient has never smoked cigarettes"]
Marijuana usage: [text default="not applicable"]
Drug use: [textarea default="not applicable"]
EtOH: [text]
Hobbies: [text]
Safety Concerns: [textarea default="none"]
ADLs: [textarea name="ADLs" default="Patient ***is/is not*** capable of ***tasks*** independently." fillable="true"]
Sources of stress: [text]
Sexual Activity: [textarea]

General: denies [checkbox name="general" value="weight change|fever|fatigue|dizziness|sleep troubles"] admits [text]
Skin: denies [checkbox value="rash|dry skin|nail changes|new moles|abnormal hair growth|skin lump|sores"]admits [text]
HEENT: denies [checkbox value="headache|head injury|wears glasses/contacts|blurred vision|pain in or around eyes|red eyes|spots in vision|tchy eyes|hearing loss|uses hearing aids|ear ache|tinnitus|rhinorrhea|frequent colds|nosebleeds|sore throat|bleeding gums|wears dentures or partial|losing teeth |broken teeth|hoarseness"] admits [text]
Neck: denies [checkbox name="neck" value="swollen glands|stiffness|pain|difficulty swallowing "] admits [text]
Respiratory: denies [checkbox name="respiratory" value="shortness of breath cough|coughing sputum|coughing blood|asthma|wheezing|COPD|snores at night|sleep apnea"] admits [text]
Chest: denies [checkbox name="chest" value="skin changes|masses/lumps|nipple discharge|pain of or around areola|performs self-breast exams"] admits [text]
Cardiovascular: denies [checkbox value="hypertension|heart murmur|hx of rheumatic fever|chest pain|angina|palpitations|edema|vericose veins|claudication|Hx of clots"] admits [text]
GU: denies [checkbox name="GU" value="increased frequency|decreased frequency|nocturia|hematuria|pain on urination|change in color|chage in odor|Hx of kidney stones|Hx of bladder trouble|urinary incontinence"][text]
Genital: denies [checkbox name="genital" value="PMDD|vaginal disccharge|vaginal pruritis|vaginal sores|unexplained vaginal bleeding|bleeding after intercourse|pain with intercourse|menopausal/hormonal concerns|penile discharge|testicular pain|testicular masses|inguinal hernia|decreased sexual funtion|decreased sexual satisfaction|Hx of STI"] admits [text]
GI: denies [checkbox name="GI" value="increased appetite|decreased appetite|heartburn|abdominal pain|belching|increased flatulence|nausea|vomiting|diahhra|constipation|yellowing of skin|yellowing of eyes|gallstones"] admits [text]
MSK: denies [checkbox value="muscle weakness|muscle pain|arthritis|joint pain|joint stiffness|decreased ROM !!!!|Hx of gout"] admits [text]
Psych: denies [checkbox value="recent mood change|anxiety|depression|changes in memory|insomnia|anhedonia"] admits [text]
Neuro: denies [checkbox value="fainting|loss of sensation/numbness|tingling|weakness|seizures|paralysis|involuntary movements|lightheaded|confused|difficulty balancing or walking|decrease in coordination|decrease in concentration"] admits [text]
Heme: denies [checkbox value="Hx of anemia|easy bruising or bleeding|Hx of blood transfusions"] admits [text]
Endocrine: denies [checkbox value="excessive sweating|excessive thirst|heat intolerance|cold intolerance|bracycardia"] admits [text]

General: [textarea default="Patient is alert, appropriately dressed and groomed, displaying approporate mood and affect."]
Vitals: [textarea name="vitals" default="height ******, weight ******, BP ****** mmHg, Pulse ****** bpm ***regular/irregular***, RR ****** respirations/minute, Temp ******" fillable="true"]
Skin: [textarea default="Skin normal color, texture and turgor with no lesions or eruptions."]
HEENT:[checkbox value="NCAT|Face symmetrical w/out lumps or bulges|Skin tone appears even and of appropriate color|Hair is of average texture and even distribution|MMM|throat clear|tongue without lesions or plaques|no swelling or erythema of gums, mucosa, or pharynx|tonsils are +1 b/l and without tonsiliths|Auricles without lesions|Earrings present in lobes b/l|Tympanic membranes appear intact with visible landmarks and cone of light b/l|External auditory canals patent and free of cerumen |Hearing grossly intact b/l|No nasal discharge|Conjunctiva pink|Conjunctiva pale|Sclera white|Icteric sclera|Sclerae anicteric|Cornea without opacities|Corneal opacities present. Lacrimal glands, without swelling, tearing, or dryness.|PERLLA|Extraocular movements intact|Vision grossly intact.|Funduscopic examination is unremarkable|Brows, lids, and lashes intact|20/20 Snellen without visual field deficit |Nose symmetrical, without tenderness. Nares patent. Turbinates without inflammation|Lips, and gums without lesions|Good dentition|no missing teeth|Uvula is midline|Posterior pharynx without erythema or exudate.|Frontal and maxillary sinuses without tenderness|Frontal and maxillary sinuses tender b/l to palpation"]
Neck: [textarea default="FROM. Neck supple, non-tender without lymphadenopathy, masses or thyromegaly."]
Respiratory: [checkbox value="resonate to percussion b/l|Dull to percussion at ---|Clear to auscultation b/l|Chest expansion symmetrical|Tactile fremitus equal b/l|No rhonchi, rales, expiratory wheezing, inspiratory wheezing|diminished breath sounds|Labored breathing |Rate is normal|Rate tachypnic"]
Breast:[textarea default="No breast masses, tenderness, asymmetry, nipple discharge or axillary lymphadenopathy."]
Cardiovascular:[checkbox value="S1/S2, no S3/S4|soft S1, normal S2, no S3/S4|S1/S2, S3 present, no S4|S1/S2, no S3, S4 present|no murmur, rubs, or gallops|no palpable heaves or thrills|bounding apical impulse|laterally displaced apical impulse|holosystolic murmur|midsystolic murmur|late systolic murmur|diastolic murmur|loudness 1/6|loudness 2/6|loudness 3/6|loudness 4/6|loudness 5/6|loudness 6/6|rhythm is regular|rhythm is regularly irregular|rhythm is irregularly irregular|Peripheral pulses are 2+ throughout|Peripheral pulses are diminished|No carotid bruits|Carotid bruits on the left|Carotid bruits on the right|Bilateral Carotid bruits|Carotid upstrokes are brisk|No JVD b/l|JVD at---|Extremities warm and without edema|Lower extremeities cool to touch|Upper extremities cool to touch.|Peripheral edema b/l|R>L|L>R|no clubbing of nails or cyanosis|cyanonsis present|clubbing of fingernails|Vericose veins ----"] [text]
Abdominal: Abdomen appears [checkbox value="obese|soft|flat|scaphoid|rigid|distended|tympanic to percussion|no hepatomegaly|hepatomegaly present|no splenomegaly|splenomegaly present|no tattoos, scars, moles, lesions, telangiectasia|RUQ scar|midline scar|RLQ scar|suprapubic scar|right flank scar|left flank scar|active bowel sounds |diminished bowel sounds |hyperactive bowel sounds|no bruits|abdominal bruit at ---|right femoral artery bruit|left femoral artery bruit|bilateral femoral bruits|no guarding|no rebound tenderness|rebound tenderness|no referred pain|no tenderness to palpation|tender to palpation at ---|suprapubic tenderness|periumbilical tenderness|epigastric tenderness|diffuse tenderness|RLQ tenderness|positive Rovsing's|positive obturator sign|positive psoas sign|mass at ---|hernia at ---|no palpable fluid wave|shifting fluid wave present|no tenderness to percussion of CVA b/l|Left CVA tender to percussion |Right CVA tender to percussion"] [text]
MSK: [textarea default="Strength, sensation, and reflexes are normal. no pain with palpation. Digits normal. No joint effusions or crepitus. No localized tenderness. FROM. normal curvature: no localized tenderness. Full ROM."] 
Neuro: [checkbox value="steady coordinated gait|abnormal gait|Rhomberg test negative|Rhomberg test positive|Cranial nerves II-XII intact|sensation to soft touch intact |Babinski negatve|Babnski positive|Biceps reflexes +2 b/l|Triceps refelex +2 b/l|Brachioradialis reflex +2 b/l|Patellar reflex +2 b/l|Ankle reflex +2 b/l|"][textarea]
Psych: [checkbox value="displays appropriate mood and affect|intact logic and reasoning|displays mania|maintains eye contact|avoids eye contact|makes no eye contact|oriented to person, place, and time|PHQ-9 score of --|Mini-cog Exam --/30|Speech is fluent and clear|Patient appears lethargic|Mood is depressed"][textarea]

Labs & Tests: [textarea]

Assessment: [textarea]

Problem List: [textarea]

References: [textarea]
Patient name:
History provided by:


Date began:

Ctrl + (or )

Remitting factors:

Relieving factors:

Associated Symptoms:

Symptoms are now:

Childhood Illnesses:

Adult Illnesses:


Other Hospitalizations:


OB/Gyn: Ctrl + (or )




Alternative med:

Father: ageyrs.
Mother: ageyrs.



Admits FamHX of:
Denies FamHx of:

Marital Status:
Living arrangements: Ctrl + (or )

Cigarette smoking:
Marijuana usage:
Drug use:

Safety Concerns:

ADLs: Ctrl + (or )

Sources of stress:
Sexual Activity:

General: denies admits
Skin: denies admits
HEENT: denies admits
Neck: denies admits
Respiratory: denies admits
Chest: denies admits
Cardiovascular: denies admits
GU: denies
Genital: denies admits
GI: denies admits
MSK: denies admits
Psych: denies admits
Neuro: denies admits
Heme: denies admits
Endocrine: denies admits


Vitals: Ctrl + (or )




Abdominal: Abdomen appears



Labs & Tests:


Problem List:


Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.33, 116 form elements, 151 boilerplate words, 40 text boxes, 38 text areas, 1 dates, 35 checkboxes, 2 drop downs, 446 total clicks
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