Geriatric Exam

GENERAL: [checkbox name="variable_1" value=" Well nourished|Obese|Thin|Frail|Cachectic|Well Groomed|Unkempt|NAD|Anxious|Lethargic|Tearful|Alert|Cooperative|Conversant"][text name="variable_1" default=", "]
EYES: [checkbox name="variable_2" value=" Lids Normal|Conjunctiva Normal|PERRL|EOMI|Glasses|No Glasses|Poor Vision|Blindness|No Blindness|No red eye|No Discharge"][text name="variable_2" default=", "]
ENT: [checkbox name="variable_3" value=" Hearing Aides|No Hearing Aides|Decreased Hearing|No Decreased Hearing|Oral Mucosa Moist|Oral Mucosa Dry|Poor Dentition|Edentulous|Dentures|No Dentures|Decreased dentition"][text name="variable_3" default=", "]
RESP: [checkbox name="variable_4" value=" Normal Effort|Labored Breathing|Tachypnea|Hypopnea|Apnea|Auscultation Clear|Rales/Rhonci|Wheezes|Decreased Breath Sounds|DOE|No increased WOB"][text name="variable_4" default=", "]
CVS: [checkbox name="variable_5" value=" HR Normal|Tachycardia|Bradycardia|Regular Rhythm|Irregular Rhythm|Murmur|No Murmur|Pacemaker|No Pacemaker|Bilateral Pedal Edema|Right Pedal Edema|Left Pedal Edema|Bilateral Pedal Edema (R>L)|Bilateral Pedal Edema (L>R)|No Pedal Edema|Pedal Pulses 2+ bilaterally|Pedal Pulses Decreased Bilaterally"][text name="variable_5" default=", "]
GI: [checkbox name="variable_6" value=" BS Normal|BS Hypotonic|BS Hypertonic|BS Absent|Tenderness|No Tenderness|Mass|No Mass"][text name="variable_6" default=", "]
M/S: [checkbox name="variable_7" value=" Spine Kyphotic|Tenderness to Palpation|Deformities|Muscle Atrophy|Decreased ROM|Contractures|Gait Independent|Non-Ambulatory|Aide|Decreased Muscle Strength"][text name="variable_7" default=", "]
GU: [checkbox name="variable_8" value=" Foley Cath|No Foley Cath|Suprapubic Tenderness|No Suprapubic Tenderness|Incontinent|Continent"][text name="variable_8" default=", "]
NEURO: [checkbox name="variable_9" value=" CN's Intact|Sensation Intact|Decreased Sensation|Tremors|No Tremors|Increased Tone"][text name="variable_9" default=", "]
PSYCH: [checkbox name="variable_10" value=" Alert|Oriented to Person|Oriented to Person/Place|Oriented x3|Confused|Flat|Cooperative|Distrustful|Conversant|Delusional|Agitated|Lethargic|Unresponsive"][text name="variable_10" default=", "]
SKIN: [checkbox name="variable_11" value=" Rash|No rash visible on exposed skin|Dermatitis|No dermatitis|Wound|No Wound|Infection|No Infection|Atypical Lesion|Bruises|Hemosiderin deposits|Venous stasis"][text name="variable_11" default=", "]
GENERAL:
EYES:
ENT:
RESP:
CVS:
GI:
M/S:
GU:
NEURO:
PSYCH:
SKIN:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.5, 22 form elements, 12 boilerplate words, 11 text boxes, 11 checkboxes, 130 total clicks
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