Psychiatry
Loading Add to Favorites
Share
Tweet
Cite
*Chief Complaint*
Date and Time of Service:[date default="today"] [text size="8"]
Patient is admitted to the IOP for [checkbox value="depression|anxiety|psychosis|substance abuse|cognitive impairment|impulsivity|mood lability|sleep disturbance|alcohol dependence|opiate dependence"] [textarea memo="other" default="" rows="1"]
[textarea memo="quotes" default="" rows="1"]

*Interval History*
Patient remains [comment memo="SYMPTOM"][checkbox value="depressed|anxious|aggressive|impulsive|inattentive|irritable|withdrawn|unable to sleep|delusional|auditory hallucinations|visual hallucinations"][textarea memo="other" default="" rows="1"].
Which is described as[comment memo="SEVERITY "][checkbox value=" the same as it has been| better| somewhat worse than it has been| significantly worse than it has been"][textarea memo="other" default="" rows="1"]
The patient notices that it is sometimes improved by [comment memo="Modifying factors "][checkbox value="talking to someone|being alone|doing something physical like walking|doing something that is distracting"][textarea memo="other" default="" rows="1"]


CURRENT ENCOUNTER HX & CONTENT
[textarea rows="8"]
[checkbox value="Client: |Parent: |Grandparent: "][checkbox value="Primary complaint is "][textarea rows="1"][checkbox value=" which is "][checkbox value="better.|worse.|same.|new."][checkbox value=" Exacerbating factors include "][text size="10"][checkbox value=" Alleviating factors include "][text size="10"][checkbox value=" with good effect. | with fair effect. | with minimal effect. "][checkbox value="Client:|Parent:|Grandparent:"][checkbox value=" Primary complaint is described as being "][checkbox value="tolerable.|intrusive.|debilitating.|mild."]

[checkbox value="Client: |Parent: |Grandparent :"][checkbox value="Alternative complaint is "][textarea rows="1"][checkbox value=" which is "][checkbox value="better.|worse.|same.|new."] [checkbox value="Exacerbating factors include "] [text size="10"][checkbox value=" Alleviating factors include "][text size="10"][checkbox value=" with good effect. | with fair effect. | with minimal effect. "][checkbox value="Client:|Parent:|Grandparent:"][checkbox value=" Alterntive complaint is described as being "][checkbox value="tolerable.|intrusive.|debilitating.|mild."]

[checkbox value="Client: |Parent: |Grandparent: "][checkbox value="Current opinion of medications is that "][checkbox value="they are working|they are not working|they cannot tell if they are working|they are making things worse|and they would like them to be adjusted. |and they would like them continued. |and they would like them to be stopped. |and they are uncertain if they should continue taking them. "] [textarea rows"1"][checkbox value="Patient's current attitude toward taking medications is "][checkbox value="enthusiastic.|cooperative|adherant.|agreeable.|oppositional.|ambivalent.|apathetic.|indifferent."] [checkbox value=" Medication adherence has been "][checkbox value="good|fair|poor|due to patient frequently forgetting doses|due to patient refusing to take medications|and patient is independent in taking medications.|and patient requires a significant amount of support from caregiver."] [textarea rows"1"]

[checkbox value="Patient denies "][checkbox value="Suicidal ideation|Homicidal ideation|Self-harm thoughts|Auditory Hallucinations|Visual Hallucinations|Tactile Hallucinations|Difficulty with sleep|Difficulty with appetite|Mood Instability|Adverse effects of medications|Pain/physical complaints"]
[checkbox value="Patient reports positive for "][checkbox value="suicidal ideation|homicidal ideation|self-harm thoughts|auditory hallucinations|visual hallucinations|tactile hallucinations|difficulty with sleep|difficulty with appetite|mood instability|adverse effects of medications|pain/physical complaints"]
Affect is [checkbox value="flat|blunted|constricted|labile|bright"]
Mood is [checkbox value="anxious|dysphoric|depressed|irritable|tearful|sad|agitated|fearful|euthymic|euphoric"]
Thought process presents as [checkbox value="reality based|disorganized|circumstantial|tangential|flight of ideas|loose association|perseverative|thought blocking|ideas of reference|grandiose|paranoid|persecutory|religious|somatic|self accusatory"]
Speech is [checkbox value="regular rate and rhythm|rapid|slow|rambling|slurred|monotone|pressured|laconic"]
Gait is [checkbox value="regular|irregular|shuffling|unsteady"]
[checkbox value="No observed "][checkbox value="psycho-motor agitation|internal preoccupation|response to internal stimuli"]
[checkbox value="Patient displays "][checkbox value="internal preoccupation|response to internal stimuli|psychomotor agitation|difficulty following simple tasks|difficiulty responding to questions|difficulty with cognitive processing|difficulty participating in interview/therapy process"]

PAST PSYCH HX
[textarea rows="8"]
Substance/s misuse: [checkbox value="None|Unable to obtain as student|No additions, deletions, or revisions|Cannabis|Heroin|Prescription Pain medication|Stimulants|Hallucinogens|Cocaine|Alcohol|Tobacco|Caffeine"] [textarea rows="1"]
Past psychiatric diagnoses: [checkbox value="None|Unable to obtain as student|No additions, deletions, or revisions|Depression|Anxiety|ADHD|OCD|PTSD|Oppositional Defiant Disorder|Autism Spectrum Disorder|Bipolar Disorder I|Bipolar Disorder II|Schizophrenia|Schizoaffective disorder|Borderline Personality Disorder|Antisocial Personality Disorder|Mood Disorder"] [textarea rows="1"]
Abuse/Trauma: [checkbox value="None|Unable to obtain as student|No additions, deletions, or revisions|Verbal/Physical abuse as child|sexual abuse|witnessing domestic violence|neglect|bullying|domestic violence|assault|death of a loved one"]
Violence:[checkbox value="None|Unable to obtain as student|No additions, deletions, or revisions|assaultive to siblings|assaultive to parents|assaultive to staff|unprovoked|as a result of limit setting|when psychotic|resulting in significant injury of victim"]
Legal History/issues: [checkbox value="None|No additions, deletions, or revisions|assault charges|protection from abuse order|DHHS involvement|pending court date|probation|to be released into police custody after completion of treatment"]
Suicide/homicide attempts/gestures: [checkbox value="None|Unable to obtain as student|No additions, deletions, or revisions|overdose|hanging|cutting|walking into traffic|jumping off bridge|threatened life of others"] [textarea rows="1"]
Prior Treatment or Therapy inpatient/outpatient: [checkbox value="None|Unable to obtain as student|No additions, deletions, or revisions|One inpatinet psychiatric hospitalization|multiple inpatient psychiatric hospitalizations|long term state hospital admissions|short term inpatient hospitalizations|crisis unit stays|partial hospitalization program|outpatient psychiatry|outpatient therapy|case management|community support worker|behavior plan in school|school counselor|primary care provider|dental"] [textarea rows="1"]

Family/Significant other/social connectedness - family of origin -
[checkbox value="Unable to obtain as student|No additions, deletions, or revisions"] [checkbox value="Patient lives"] [checkbox value="Alone|not in contact with known family.|With parent/s.|with parent/s and sibling/s.|with other family members.|with significant other.|in assisted living/nursing home."]
[checkbox value="Has a guardian who is "][checkbox value="Mother.|Father.|Grandparent.|DHHS worker."][checkbox value=" Has payee."]
[checkbox value="Maternal history of: "][checkbox value="alcohol use|opiate use|polysubstance use|depression|anxiety|bipolar disorder|schizophrenia|violence|suicide attempts|completed suicide"][checkbox value="Paternal history of: "][checkbox value="alcohol use|opiate use|polysubstance use|depression|anxiety|bipolar disorder|schizophrenia|violence|suicide attempts|completed suicide"][checkbox value="Sibling history of: "][checkbox value="alcohol use|opiate use|polysubstance use|depression|anxiety|bipolar disorder|schizophrenia|violence|suicide attempts|completed suicide"]

Hobbies/Acitivities/Habits/Occupation
[checkbox value="No additions, deletions, or revisions|Unable to obtain as student|school|video games|spending time with friends|sports|art|reading|writing|swimming"][textarea rows="2"]

PAST/CURRENT MED HX
[textarea rows="2"][checkbox value="Unremarkable|No additions, deletions, or revisions|Cardiovascular history:|Chest pain/angina|CHF|HTN|Hyperlipidemia|cardiac surgeries|DVT||Respiratory history:|asthma|COPD|bronchitis|sleep apnea||Communicable Disease:|Hep A|Hep B|Hep C|HIV/AIDS|TB||Neurological History:|Chronic Pain|Head Injury|Seizure Disorder|Migraine|Chronic headache||Medical Device History:|Bipap/CPAP|Oxygen|Pacemaker|Insulin Pump|Cane|Walker|Dentures|Glasses||Musculoskeletal history:|arthritis|amputation|back/neck problems|congenital abnormalities|fibromyalgia|osteoporosis|metal implants|Endocrine/Metabolic|Diabetes-insulin dependent|diabetes-non-insulin dependent|hypothyroid||Integumentary:|Ulcers|eczema|psoriasis|skin breakdown related to:||EENT history:|ear problems|eye problems|nasal/sinus problems||Sexual/Reproductie history:|Abnormal bleeding/discharge|birth control|menopause|sexually active|sexually transmitted disease|recent pregnancy|currently pregnant"]


MSE
Appearance: [select value="alert and oriented to time, place and person|OBTUNDED|DISORIENTED|HYPERALERT|-"],[select value="well kempt|POORLY KEMPT|appropriately dressed|INAPPROPRIATELY DRESSED|appropriately groomed|INAPPROPRIATELY GROOMED|DISHEVELED|-"],[select value="normal posture|SLUMPED|RIGID|TENSE|-"].[textarea cols="20" rows="1"]
Behavior: [select value="calm|RESTLESS|AGITATED|RETARDED|PECULIAR|IMPULSIVE|-"],[select value="interactive|WITHDRAWN|-"],[select value="eye contact good|eye contact AVOIDANT|eye contact INTENSE|eye contact FLEETING|-"]. [textarea cols="20" rows="1"]
Attitude: [select value="cooperative|HOSTILE|OVER FRIENDLY|SECRETIVE|EVASIVE|SUSPICIOUS|APATHETIC|EASILY DISTRACTED|FOCUSED|DEFENSIVE|DEMANDING|SEDUCTIVE|-"]. [textarea cols="20" rows="1"]
Speech: [select name="spontn" value="spontaneous|NON-SPONTANEOUS|MUTISM|-"],[select name="rt" value="N reaction time|INCR REACTION TIME|DECR REACTION TIME|VARIABLE|-"],[select name="rate" value="normal rate|SLOW|POVERTY|PAUCITY|RAPID|OVERTALKATIVE|PRESSURE|-"],[select name="vol" value="normal volume|LOUD|SOFT|WHISPHER|MONOTONE|-"],[select name="rhythm" value="clear rhythm|SLURRED|HESITANT|APHASIC|-"].[textarea cols="20" rows="1"]
Mood reported as: [textarea cols="20" rows="1"],inferred as-[select value="euthymic|NOT REPORTED|ANXIOUS|DEPRESSED|DYSPHORIC|IRRITABLE|ELEVATED|EXPANSIVE|ELATED|EUPHORIC|ANGRY|HOSTILE|INDIFFERENT|DETACHED|ANIMATED|-"]
Affect: quality: [select value="euthymic|ANXIOUS|DEPRESSED|DYSPHORIC|IRRITABLE|ELEVATED|EXPANSIVE|ELATED|EUPHORIC|ANGRY|HOSTILE|INDIFFERENT|DETACHED|ANIMATED|-"], [select value="range normal|BROAD|RESTRICTED|-"], [select value="intensity normal|EXPANSIVE|BLUNTED|FLAT|LABILE|-"], [select value="congruent|INCONGRUENT|-"]
Thought form: [select value="coherent|INCOHERENT|CANNOT BE ASSESSED|NOT ENOUGH SAMPLE|-"],[select value="logical and goal directed|-|CIRCUMSTANTIAL|TANGENTIAL|LOOSENING|FLIGHTS OF IDEAS"].[select value="-|NEOLOGISM|BLOCKING|VERBAL PERSEVERATION"]. [textarea cols="20" rows="1"]
Thought content: [select value="no delusion on current evaluation|DELUSION PRESENT|CANNOT BE ASSESSED|-"],[select value="no active suicidal ideations at present| SUICIDAL IDEATIONS PRESENT|DEATH WISHES PRESENT|CANNOT BE ASSESSED|-"]. [textarea cols="20" rows="1"]
Perception: [select value="no hallucination on current evaluation|HALLUCINATION|CANNOT BE ASSESSED|-"]. [textarea cols="20" rows="1"]
Insight: [select value="present|PARTIAL|POOR|MOSTLY BLAMES OTHERS|DIFFICULTY IN ACKNOWLEDGING PRESENCE OF PSYCHIATRIC SYMPTOMS|CANNOT BE ASSESSED|-"]. [textarea cols="20" rows="1"]
Judgment: [select value="intact|IMPAIRED|CANNOT BE ASSESSED|-"]. [textarea cols="20" rows="1"]
Cognition: [select value="intact|ABNORMALITIES PRESENT|PENDING|CANNOT BE ASSESSED|-"]. [textarea default="normal attention, concentration, intact ability to recall recent and remote information, normal abstraction" cols="50" rows="3"]

PMH:

General Health and Strength:
[textarea name="field_name" default="sample text"]

Significant Childhood Illnesses:
[textarea name="field_name" default="sample text"]

Major Adult Illnesses or Chronic Illnesses:
[textarea name="field_name" default="sample text"]


Limitation of abilities:
--Hearing: [checklist name="field_name" value="Unilateral|Bilateral|sensory loss|neural loss|sensorineural loss|wears hearing aid"]

--Vision: [checklist name="field_name" value="legally blind|glasses|contacts"]
--Speech:[text name="field_name" default="sample text"]

--Gait:[checklist name="field_name" value="frequent falls|cane|tripod cane|quad-cane|walker|wheeled walker|frequent falls|rollator|wheelchair|electric wheelchair"]

--Dexterity:[textarea name="field_name" default="sample text"]

--Swallow: [textarea name="field_name" default="chopped|ground|soft|pureed|nectar thick liquid|honey thick liquid"|full dentures|upper dentures|lower dentures|partials|caps"]


Review of Systems:

--Constitutional: c/o [checklist name="field_name" value="fatigue|fever|chills|malaise|generalized weakness|diffuse pain|sleeping problems|night sweats|weight changes"] [text name="field_name" default="sample text"]. Denies: [checklist name="field_name" value="fatigue|fever|chills|malaise|generalized weakness|diffuse pain|sleeping problems|night sweats|weight changes"].

--Head: c/o [checklist name="field_name" value="headaches|dizziness|syncope|dizziness|sinus pain|LOC"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="headaches|dizziness|syncope|dizziness|sinus pain|LOC"].

--Eyes: c/o [checklist name="field_name" value="vision loss|blurriness|blind spots|floaters|diplopia|photophobia|eye pain|halos|erythemia|drainage|change in appearance|dryness"].[text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="vision loss|blurriness|blind spots|floaters|diplopia|photophobia|eye pain|halos|erythemia|drainage|change in appearance|dryness"].

--Ears: c/o [checklist name="field_name" value="ear pain|tinnitus|hearing loss|fullness in ears|drainage|drainage|vertigo|frequent infections"] [text name="field_name" default="sample text"]. [checklist name="field_name" value="ear pain|tinnitus|hearing loss|fullness in ears|drainage|drainage|vertigo|frequent infections"].

--Nose: c/o [checklist name="field_name" value="loss of smell|obstruction|epistaxis|drainage|congestion|tenderness|sinus pain|lesions"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="loss of smell|obstruction|epistaxis|drainage|congestion|tenderness|sinus pain|lesions"].

--Mouth and Throat: c/o [checklist name="field_name" value="hoarseness|change in voice B|sore throat|bleeding in mouth|hemoptysis|swollen gums|recent abscess |recent extractions|soreness in mouth|soreness in tongue|ulcers|change in taste"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="hoarseness|change in voice|sore throat|bleeding in mouth|hemoptysis|swollen gums|recent abscess |recent extractions|soreness in mouth|soreness in tongue|ulcers|change in taste"].

--Neck: c/o [checklist name="field_name" value="neck pain|stiffness|edema"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="neck pain|stiffness|edema"] [text name="field_name" default="sample text"].

--Cardiac: c/o [checklist name="field_name" value="chest pain|dyspnea| orthopnea|edema|palpitations|shortness of breath with activities|loss of consciousness|paroxysmal nocturnal dyspnea|need to elevate head at night due to SOB"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="chest pain|dyspnea| orthopnea|edema|palpitations|shortness of breath with activities|loss of consciousness|paroxysmal nocturnal dyspnea|need to elevate head at night due to SOB"].

--Vascular: c/o [checklist name="field_name" value="claudication|color changes in extremities|parathesias|coldness in extremities|tendency to bruise"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="claudication|color changes in extremities|parathesias|coldness in extremities"].

--Respiratory: c/o [checklist name="field_name" value="Pain with Respiration|Dyspnea|Cyanosis|Coughing|Wheezing|Sputum|Hemoptysis|Night Sweats|shortness of breath|exercise intolerance with activity"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="Pain with Respiration|Dyspnea|Cyanosis|Coughing|Wheezing|Sputum|Hemoptysis|Night Sweats|shortness of breath|exercise intolerance with activity"].

--Gastrointestinal: c/o [checklist name="field_name" value="appetite changes|heartburn|dysphagia|abdominal pain|nausea|vomiting|diarrhea|constipation|change in stools|flatulence|anorexia|hematemesis |intolerance to foods|painful bowel movements|bloating|cramping|anorexia|bright red blood per rectum|foul smelling dark black tarry stools|tenesmus"] [text name="field_name" default="sample text"]. Denies[checklist name="field_name" value="appetite changes|heartburn|dysphagia|abdominal pain|nausea|vomiting|diarrhea|constipation|change in stools|flatulence|anorexia|hematemesis |intolerance to foods|painful bowel movements|bloating|cramping|anorexia|bright red blood per rectum|foul smelling dark black tarry stools|tenesmus"]

--Endocrine: c/o [checklist name="field_name" value="thyroid tenderness|thyroid enlargement|excessive thirst|excessive hunger/excessive urination|heat intolerance|cold intolerance|unexplained Weight changes|changes in face or body hair|striae|increased hat or glove size|mood swings|sweaty|diarrhea|oligomenorrhoea|tremor, palpitations|visual disturbances|feeling slow|feeling tired|depression thin hair| croaky voice|heavy periods|constipation|dry skin|orthostatic symptoms, darkening of skin in non-sun exposed places"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="thyroid tenderness|thyroid enlargement|excessive thirst|excessive hunger/excessive urination|heat intolerance|cold intolerance|unexplained Weight changes|changes in face or body hair|striae|increased hat or glove size|mood swings|sweaty|diarrhea|oligomenorrhoea|tremor, palpitations|visual disturbances|feeling slow|feeling tired|depression thin hair| croaky voice|heavy periods|constipation|dry skin|orthostatic symptoms, darkening of skin in non-sun exposed places"].

--Hematological/Lymphatic: c/o [checklist name="field_name" value="anemia|purpura|petechia| prolonged or excessive bleeding after dental extraction/injury|bruising|blood clots|enlarged lymph nodes|tender lymph nodes"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="anemia|purpura|petechia| prolonged or excessive bleeding after dental extraction/injury|bruising|blood clots|enlarged lymph nodes|tender lymph nodes"].

--Genitourinary: c/o [checklist name="field_name" value="dysuria|urinary frequency|urinary urgency| hematuria|flank pain|suprapubic pain|nocturia|polyuria|dark or discolored Urine|hesitancy|terminal dribbling|loss of force of stream|loss or urine with laughing, coughing, sneezing, exercise, position changes|loss of sensation|loss of control"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="dysuria|urinary frequency|urinary urgency| hematuria|flank pain|suprapubic pain|nocturia|polyuria|dark or discolored Urine|hesitancy|terminal dribbling|loss of force of stream|loss or urine with laughing, coughing, sneezing, exercise, position changes|loss of sensation|loss of control"]

Reproductive (female): c/o [checklist name="field_name" value="change in cycle duration and frequency|vaginal bleeding irregularities|vaginal discharge|vaginal pain|menstrual pain|changes in sexual arousal or libido|infertility|painful intercourse"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="change in cycle duration and frequency|vaginal bleeding irregularities|vaginal discharge|vaginal pain|menstrual pain|changes in sexual arousal or libido|infertility|painful intercourse"]. Gravida [text name="field_name" default="sample text"] Para [text name="field_name" default="sample text"] Abortus [text name="field_name" default="sample text"]. LMP: [text name="field_name" default="sample text"].

Reproductive (male): c/o [checklist name="field_name" value="difficulty with erection|difficulty with sexual arousal|lack of stamina|difficulty with emissions|testicular pain"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="difficulty with erection|difficulty with sexual arousal|lack of stamina|difficulty with emissions|testicular pain"].

--Musculoskeletal: c/o [checklist name="field_name" value="joint pain or tenderness|joint swelling|muscles pain|ROM changes|stiffness |bony deformity|misalignment"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="joint pain or tenderness|joint swelling|muscles pain|ROM changes|stiffness |bony deformity|misalignment"].

--Integument:
c/o [checklist name="field_name" value="pruritis|rashes|stria|lesions|wounds|pigmentation changes|acanthosis nigricans|nodules|lumps/bumps|excessive dryness|discoloration|texture changes|eruptions"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="pruritis|rashes|stria|lesions|wounds|pigmentation changes|acanthosis nigricans|nodules|lumps/bumps|excessive dryness|discoloration|texture changes|eruptions"].

--Neurological: c/o [checklist name="field_name" value="change in sight|changes in smell|change in hearing|changes in taste|change in sensation|faints|fits|funny turns|headache|paraesthesias|numbness|paralysis|limb weakness|poor balance|loss of coordination|speech problems|seizures|dizziness|headaches|tremors|memory loss"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="change in sight|changes in smell|change in hearing|changes in taste|change in sensation|faints|fits|funny turns|headache|paraesthesias|numbness|paralysis|limb weakness|poor balance|loss of coordination|speech problems|seizures|dizziness|headaches|tremors|memory loss"].

--Psychiatric: c/o [checklist name="field_name" value="depression|change in sleep patterns|anxiety|difficulty concentrating|difficulty paying attention|change in body image|changes in work and school performance|paranoia|anhedonia|lack of energy|episodes of mania|episodic change in personality|sexual or financial binges|irritability|tension|suicidal thoughts|homicidal thoughts"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="depression|change in sleep patterns|anxiety|difficulty concentrating|difficulty paying attention|change in body image|changes in work and school performance|paranoia|anhedonia|lack of energy|episodes of mania|episodic change in personality|sexual or financial binges|irritability|tension|suicidal thoughts|homicidal thoughts"]


--General Appearance:
LOC:[checklist name="field_name" value="Alert|Awake|Aware|Asleep|Responds to Verbal Stimulus|Responds to Pain|Unresponsive |Lethargic|Unconscious"]
Gait: [text name="field_name" default="sample text"]
Hygiene and Grooming:[text name="field_name" default="sample text"]
Affect:[text name="field_name" default="sample text"]
Nutrition: [checklist name="field_name" value="well-nourished|cachexic"]
Distress: [checklist name="field_name" value="observable pain cues|appears in no acute distress"]

--HEENT:
HEAD: Saw on insepction: [checkbox name="field_name" value="NC/AT"] [text name="field_name" default="sample text"].
EYES: Saw on inspection: [checklist name="field_name" value="PERRLA|EOMI|anticeteric|Injection|No injection|Papilledema|No papilledema|Cornea clear|cornea cloudy"], Fundus: [text name="field_name" default="sample text"], Eyebrows:[text name="field_name" default="sample text"] eyelids: [text name="field_name" default="sample text"] sclera: [text name="field_name" default="sample text"], Conjuctiva: [text name="field_name" default="sample text"]. Felt on Palpation: [text name="field_name" default="sample text"]. Snellen: [text name="field_name" default="sample text"]. Jaeger Chart: [text name="field_name" default="sample text"]. Ichihara Chart: [text name="field_name" default="sample text"]
EARS: Saw on inspection: [checklist name="field_name" value="discharge|no discharge|inflammation|no inflammation|TM intact|TM not intact|TM bulging|TM Concave|TM Gray|TM Discolored|TM cloudy|Visible bony structures"]. Felt On Palpation: [text name="field_name" default="sample text"]. Weber Test: [text name="field_name" default="sample text"]. Rinne Test:
Nose: Saw on inspection: [checklist name="field_name" value="Nares red|nose symmetric|nose assymetric|Nares patent|Nares not patent|Mucous membranes moist and pink| mucous membranes moist and red|mucous membranes moist and grey|polyps present|no septal defect|septal defect"] [text name="field_name" default="sample text"], discharge: [text name="field_name" default="sample text"]. Felt on palpation: Frontal Sinuses: [text name="field_name" default="sample text"] Maxillary Sinuses: [text name="field_name" default="sample text"], Trans-illumination: [text name="field_name" default="sample text"], [text name="field_name" default="sample text"]
Mouth/Throat: Saw on inspection: Lips:
[text name="field_name" default="sample text"], Dental Caries: [text name="field_name" default="sample text"], Alignment: [text name="field_name" default="sample text"], Oropharynx: [text name="field_name" default="sample text"], Uvula: [text name="field_name" default="sample text"], Tonsils: [text name="field_name" default="sample text"], Tongue: [text name="field_name" default="sample text"], Gag Reflex: [select name="field_name" value="present|not present"]. [text name="field_name" default="sample text"]

--NECK: Saw on inspection [checklist name="field_name" value="Visible goiter|No visible Goiter|Edema|Discoloration"] [text name="field_name" default="sample text"], Felt on palpation: [checklist name="field_name" value="thrill|no thrill|LAD|No LAD|Neck supple|Neck rigid"] [text name="field_name" default="sample text"]. Lymph nodes: Aneterior Cervical: [text name="field_name" default="sample text"]. Posterior Cervical:[text name="field_name" default="sample text"]
Tosillar: [text name="field_name" default="sample text"] Sub-mandibular: [text name="field_name" default="sample text"]
Sub-Mental: [text name="field_name" default="sample text"] Supraclavicular: [text name="field_name" default="sample text"]. Heard on Auscultation: Bruit|No Bruit"] [text name="field_name" default="sample text"]

--RESPIRATORY:
[textarea name="field_name" default="LUNGS: symmetric expansion/accessory muscle use/no accessory muscle use/barrel chest/Clear to auscultation and percussion/dimished breath sounds/areas of consolidation/without rales/with rales/without rhonchi/with rhonchi/audible wheeze/no wheezing/audible stridor/clubbing/no clubbing"]
Cyanosis: [text name="field_name" default="sample text"]

--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|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 irregular|rhythm is irregularly irregular"][checkbox name="pulses" value="Peripheral pulses are 2+ throughout|Peripheral pulses are diminished|Peripheral pulses exam - "][conditional field="pulses" condition="(pulses).is('Peripheral pulses exam - ')"][text][/conditional][checkbox name="carotids" value="No carotid bruits|Carotid bruits on the left|Carotid bruits on the right|Bilateral Carotid bruits|Carotid pulses exam - "][conditional field="carotids" condition="(carotids).is('Carotid pulses exam - ')"][text][/conditional]. JVP: [text name="field_name" default="sample text"], Heaves/Lifts: [text name="field_name" default="sample text"] PMI:[text name="field_name" default="sample text"], [text name="field_name" default="sample text"],

--MUSCULOSKELETAL:
--JOINTS:
[textarea name="field_name" default="sample text"]
[textarea default="Neck: Range of motion with normal flexion, extension, right rotation, and left rotation. There is no palpable paraspinal muscle spasm."]
[textarea default="Upper extremity muscle strength is normal bilaterally. Sensation is normal bilaterally. Reflexes: normal and symmetric at biceps, triceps, brachioradialis"]
[textarea default="C spine x-ray: normal, without loss of cervical lordosis, no degenerative changes"][/conditional][conditional field="Q1" condition="(Q1).is('Back Pain')"]
[textarea default="General Appearance: No distress. Patient able to ambulate well. Gait is not antalgic."]
[textarea default="Straight leg raising negative bilaterally for radicular symptoms."]
[textarea default="Sensory exam in the legs is normal. "]
[textarea default="Knee reflexes are normal and symmetric."]
[textarea default="Ankle reflexes are normal and symmetric"]
[textarea default="Strength is normal and symmetric."]
[textarea default="No paraspinal muscle spasm. There is no midline tenderness. ROM of spine with normal flexion, extension, lateral range of motion to the right and left, and rotation to the right and left."][/conditional][conditional field="Q1" condition="(Q1).is('Shoulder Pain')"]
[textarea default="General Appearance: no acute distress"]
[textarea default="Neck: Range of motion with normal flexion, extension, right rotation, and left rotation. There is no palpable paraspinal muscle spasm."]
[textarea default="Shoulder: Symmetrical bilaterally, FROM flex/ex/IR/ER/abduction/adduction, No erythema or edema, Nontender to palpation, Negative: Hawkins, Neers, Yergusons, Speeds, empty can, 5/5 strength biceps/triceps/grip, Radial pulse full. Cap refill <2 seconds, Sensory intact to light touch distally."][/conditional][conditional field="Q1" condition="(Q1).is('Knee Pain')"]
[textarea default="General Appearance: no acute distress
[textarea default="Knee: Normal joint contours. No effusion. Normal range of motion. Normal strength on extension and flexion against resistance. No joint line pain medially or laterally. McMurray negative for crepitus and pain medially and laterally. There is no swelling or pain over the pes anserine bursa. Collateral ligament testing shows no laxity or pain. Anterior drawer test and Lachman shows no anterior cruciate laxity. Posterior drawer negative for laxity as well. No popliteal mass or palpable tenderness."][/conditional]

--GASTROINTESTINAL:
[conditional field="short" condition="(short).is('')"][textarea cols=80 rows=5 default="ABDOMEN: soft, flat, nontender without masses or hepatosplenomegaly. Bowel sounds active. No bruits."][/conditional][checkbox memo="Long Version" name="long" value=""][conditional field="long" condition="(long).is('')"][textarea cols=80 rows=5 default="ABDOMEN: ***obese/soft/flat/rigid/distended/tympany to percussion/hepatomegaly/splenomegaly/RUQ scar/midline scar/RLQ scar/suprapubic scar/right flank scar/left flank scar***
"]
[textarea cols=80 rows=5 default="***bowel sounds active/decreased bowel sounds/increased bowel sounds/no bruits/abdominal bruit at ---/right femoral artery bruit/left femoral artery bruit/bilateral femoral bruits***"]
[textarea cols=80 rows=5 default="***no guarding/no rebound tenderness/no abdominal tenderness to palpation/suprapubic tenderness/diffuse tenderness/tender to palpation at ---/RLQ tenderness/rebound tenderness/diminished bowel sounds/hyperactive bowel sounds/guarding/Rovsing's positive/mass at ---/hernia at ---***"][/conditional]

--GENITOURINARY:
[textarea name="field_name" default="Bladder distended/bladder nondistended, Bladder firm/Bladder soft/no tenderness/suprapubic tenderness/rash to perineum/urethral meatus patent/circumcised/not circumcised/rugae present/rugae absent/moist pink vulva/uterine prolapse present/stage I/stage II/stage III/rectal prolapse present/anal wink present/anal wink absent/BCR present/BCR absent/rectal tone present/gaping anus/rectal tone impaired/stool in rectal vault/no stool in rectal vault/rectal mass present"]. Prostate: [text name="field_name" default="sample text"]
PVR: [text name="field_name" default="sample text"]. [text name="field_name" default="sample text"]

--INTEGUMENTARY:
[textarea name="field_name" default="skin warm/skin cool/skin hot/flushing/diaphoretic/poor skin turgor/good skin turgor/dry skin/xerosis/friable/pale/yellow/petechiae/purpura"].
Wounds:
[textarea name="field_name" default="sample text"]
Rashes:
[textarea name="field_name" default="sample text"]
Scars:
[textarea name="field_name" default="sample text"]

--NEUROLOGIC:
Gait: [select name="G1" value="steady coordinated gait|abnormal"][conditional field="G1" condition="(G1).is('abnormal')"][checkbox value="an unsteady uncoordinated gait|a slow unsteady gait|walks on heels and toes with out problems|has difficulty with walking"][/conditional] [text]
Rhomberg: [select value="negative|postive"] [text]
Rapid alternating movements: [select value="normal|abnormal"] [text]
Cranial nerves: [select value="II-XII intact|abnormal"] [text]
cranial nerves II-XII intact.
Sensation: [select value="intact and symmetric at upper and lower extremities bilaterally|abnormal"] [text]
Strength: [select value="intact and symmetric at upper and lower extremities bilaterally|abnormal"] [text]
Reflexes:
[checkbox memo="Right Biceps" name="RB" value=""][conditional field="RB" condition="(RB).is('')"]Right Biceps: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Left Biceps" name="LB" value=""][conditional field="LB" condition="(LB).is('')"]Left Biceps: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Right Triceps" name="RT" value=""][conditional field="RT" condition="(RT).is('')"]Right Triceps: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Left Triceps" name="LT" value=""][conditional field="LT" condition="(LT).is('')"]Left Triceps: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Right Forearm" name="RF" value=""][conditional field="RF" condition="(RF).is('')"]Right Forearm: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Left Forearm" name="LF" value=""][conditional field="LF" condition="(LF).is('')"]Left Forearm: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Right Patella" name="RP" value=""][conditional field="RP" condition="(RP).is('')"]Right Patella: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Left Patella" name="LP" value=""][conditional field="LP" condition="(LP).is('')"]Left Patella: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Right Ankle" name="RA" value=""][conditional field="RA" condition="(RA).is('')"]Right Ankle: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Left Ankle" name="LA" value=""][conditional field="LA" condition="(LA).is('')"]Left Ankle: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional]
Babinski: [select value="negative|postive"] [text]
The following other neurologic findings were found: [textarea default="none"]

--General Appearance:
LOC:[checklist name="field_name" value="Alert|Awake|Aware|Asleep|Responds to Verbal Stimulus|Responds to Pain|Unresponsive |Lethargic|Unconscious"]
Gait: [text name="field_name" default="sample text"]
Hygiene and Grooming:[text name="field_name" default="sample text"]
Affect:[text name="field_name" default="sample text"]
Nutrition: [checklist name="field_name" value="well-nourished|cachexic"]
Distress: [checklist name="field_name" value="observable pain cues|appears in no acute distress"]

--HEENT:
HEAD: Saw on insepction: [checkbox name="field_name" value="NC/AT"] [text name="field_name" default="sample text"].
EYES: Saw on inspection: [checklist name="field_name" value="PERRLA|EOMI|anticeteric|Injection|No injection|Papilledema|No papilledema|Cornea clear|cornea cloudy"], Fundus: [text name="field_name" default="sample text"], Eyebrows:[text name="field_name" default="sample text"] eyelids: [text name="field_name" default="sample text"] sclera: [text name="field_name" default="sample text"], Conjuctiva: [text name="field_name" default="sample text"]. Felt on Palpation: [text name="field_name" default="sample text"]. Snellen: [text name="field_name" default="sample text"]. Jaeger Chart: [text name="field_name" default="sample text"]. Ichihara Chart: [text name="field_name" default="sample text"]
EARS: Saw on inspection: [checklist name="field_name" value="discharge|no discharge|inflammation|no inflammation|TM intact|TM not intact|TM bulging|TM Concave|TM Gray|TM Discolored|TM cloudy|Visible bony structures"]. Felt On Palpation: [text name="field_name" default="sample text"]. Weber Test: [text name="field_name" default="sample text"]. Rinne Test:
Nose: Saw on inspection: [checklist name="field_name" value="Nares red|nose symmetric|nose assymetric|Nares patent|Nares not patent|Mucous membranes moist and pink| mucous membranes moist and red|mucous membranes moist and grey|polyps present|no septal defect|septal defect"] [text name="field_name" default="sample text"], discharge: [text name="field_name" default="sample text"]. Felt on palpation: Frontal Sinuses: [text name="field_name" default="sample text"] Maxillary Sinuses: [text name="field_name" default="sample text"], Trans-illumination: [text name="field_name" default="sample text"], [text name="field_name" default="sample text"]
Mouth/Throat: Saw on inspection: Lips:
[text name="field_name" default="sample text"], Dental Caries: [text name="field_name" default="sample text"], Alignment: [text name="field_name" default="sample text"], Oropharynx: [text name="field_name" default="sample text"], Uvula: [text name="field_name" default="sample text"], Tonsils: [text name="field_name" default="sample text"], Tongue: [text name="field_name" default="sample text"], Gag Reflex: [select name="field_name" value="present|not present"]. [text name="field_name" default="sample text"]

--NECK: Saw on inspection [checklist name="field_name" value="Visible goiter|No visible Goiter|Edema|Discoloration"] [text name="field_name" default="sample text"], Felt on palpation: [checklist name="field_name" value="thrill|no thrill|LAD|No LAD|Neck supple|Neck rigid"] [text name="field_name" default="sample text"]. Lymph nodes: Aneterior Cervical: [text name="field_name" default="sample text"]. Posterior Cervical:[text name="field_name" default="sample text"]
Tosillar: [text name="field_name" default="sample text"] Sub-mandibular: [text name="field_name" default="sample text"]
Sub-Mental: [text name="field_name" default="sample text"] Supraclavicular: [text name="field_name" default="sample text"]. Heard on Auscultation: Bruit|No Bruit"] [text name="field_name" default="sample text"]

--RESPIRATORY:
[textarea name="field_name" default="LUNGS: symmetric expansion/accessory muscle use/no accessory muscle use/barrel chest/Clear to auscultation and percussion/dimished breath sounds/areas of consolidation/without rales/with rales/without rhonchi/with rhonchi/audible wheeze/no wheezing/audible stridor/clubbing/no clubbing"]
Cyanosis: [text name="field_name" default="sample text"]

--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|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 irregular|rhythm is irregularly irregular"][checkbox name="pulses" value="Peripheral pulses are 2+ throughout|Peripheral pulses are diminished|Peripheral pulses exam - "][conditional field="pulses" condition="(pulses).is('Peripheral pulses exam - ')"][text][/conditional][checkbox name="carotids" value="No carotid bruits|Carotid bruits on the left|Carotid bruits on the right|Bilateral Carotid bruits|Carotid pulses exam - "][conditional field="carotids" condition="(carotids).is('Carotid pulses exam - ')"][text][/conditional]. JVP: [text name="field_name" default="sample text"], Heaves/Lifts: [text name="field_name" default="sample text"] PMI:[text name="field_name" default="sample text"], [text name="field_name" default="sample text"],

--MUSCULOSKELETAL:
--JOINTS:
[textarea name="field_name" default="sample text"]
[textarea default="Neck: Range of motion with normal flexion, extension, right rotation, and left rotation. There is no palpable paraspinal muscle spasm."]
[textarea default="Upper extremity muscle strength is normal bilaterally. Sensation is normal bilaterally. Reflexes: normal and symmetric at biceps, triceps, brachioradialis"]
[textarea default="C spine x-ray: normal, without loss of cervical lordosis, no degenerative changes"][/conditional][conditional field="Q1" condition="(Q1).is('Back Pain')"]
[textarea default="General Appearance: No distress. Patient able to ambulate well. Gait is not antalgic."]
[textarea default="Straight leg raising negative bilaterally for radicular symptoms."]
[textarea default="Sensory exam in the legs is normal. "]
[textarea default="Knee reflexes are normal and symmetric."]
[textarea default="Ankle reflexes are normal and symmetric"]
[textarea default="Strength is normal and symmetric."]
[textarea default="No paraspinal muscle spasm. There is no midline tenderness. ROM of spine with normal flexion, extension, lateral range of motion to the right and left, and rotation to the right and left."][/conditional][conditional field="Q1" condition="(Q1).is('Shoulder Pain')"]
[textarea default="General Appearance: no acute distress"]
[textarea default="Neck: Range of motion with normal flexion, extension, right rotation, and left rotation. There is no palpable paraspinal muscle spasm."]
[textarea default="Shoulder: Symmetrical bilaterally, FROM flex/ex/IR/ER/abduction/adduction, No erythema or edema, Nontender to palpation, Negative: Hawkins, Neers, Yergusons, Speeds, empty can, 5/5 strength biceps/triceps/grip, Radial pulse full. Cap refill <2 seconds, Sensory intact to light touch distally."][/conditional][conditional field="Q1" condition="(Q1).is('Knee Pain')"]
[textarea default="General Appearance: no acute distress
[textarea default="Knee: Normal joint contours. No effusion. Normal range of motion. Normal strength on extension and flexion against resistance. No joint line pain medially or laterally. McMurray negative for crepitus and pain medially and laterally. There is no swelling or pain over the pes anserine bursa. Collateral ligament testing shows no laxity or pain. Anterior drawer test and Lachman shows no anterior cruciate laxity. Posterior drawer negative for laxity as well. No popliteal mass or palpable tenderness."][/conditional]

--GASTROINTESTINAL:
[conditional field="short" condition="(short).is('')"][textarea cols=80 rows=5 default="ABDOMEN: soft, flat, nontender without masses or hepatosplenomegaly. Bowel sounds active. No bruits."][/conditional][checkbox memo="Long Version" name="long" value=""][conditional field="long" condition="(long).is('')"][textarea cols=80 rows=5 default="ABDOMEN: ***obese/soft/flat/rigid/distended/tympany to percussion/hepatomegaly/splenomegaly/RUQ scar/midline scar/RLQ scar/suprapubic scar/right flank scar/left flank scar***
"]
[textarea cols=80 rows=5 default="***bowel sounds active/decreased bowel sounds/increased bowel sounds/no bruits/abdominal bruit at ---/right femoral artery bruit/left femoral artery bruit/bilateral femoral bruits***"]
[textarea cols=80 rows=5 default="***no guarding/no rebound tenderness/no abdominal tenderness to palpation/suprapubic tenderness/diffuse tenderness/tender to palpation at ---/RLQ tenderness/rebound tenderness/diminished bowel sounds/hyperactive bowel sounds/guarding/Rovsing's positive/mass at ---/hernia at ---***"][/conditional]

--GENITOURINARY:
[textarea name="field_name" default="Bladder distended/bladder nondistended, Bladder firm/Bladder soft/no tenderness/suprapubic tenderness/rash to perineum/urethral meatus patent/circumcised/not circumcised/rugae present/rugae absent/moist pink vulva/uterine prolapse present/stage I/stage II/stage III/rectal prolapse present/anal wink present/anal wink absent/BCR present/BCR absent/rectal tone present/gaping anus/rectal tone impaired/stool in rectal vault/no stool in rectal vault/rectal mass present"]. Prostate: [text name="field_name" default="sample text"]
PVR: [text name="field_name" default="sample text"]. [text name="field_name" default="sample text"]

--INTEGUMENTARY:
[textarea name="field_name" default="skin warm/skin cool/skin hot/flushing/diaphoretic/poor skin turgor/good skin turgor/dry skin/xerosis/friable/pale/yellow/petechiae/purpura"].
Wounds:
[textarea name="field_name" default="sample text"]
Rashes:
[textarea name="field_name" default="sample text"]
Scars:
[textarea name="field_name" default="sample text"]

--NEUROLOGIC:
Gait: [select name="G1" value="steady coordinated gait|abnormal"][conditional field="G1" condition="(G1).is('abnormal')"][checkbox value="an unsteady uncoordinated gait|a slow unsteady gait|walks on heels and toes with out problems|has difficulty with walking"][/conditional] [text]
Rhomberg: [select value="negative|postive"] [text]
Rapid alternating movements: [select value="normal|abnormal"] [text]
Cranial nerves: [select value="II-XII intact|abnormal"] [text]
cranial nerves II-XII intact.
Sensation: [select value="intact and symmetric at upper and lower extremities bilaterally|abnormal"] [text]
Strength: [select value="intact and symmetric at upper and lower extremities bilaterally|abnormal"] [text]
Reflexes:
[checkbox memo="Right Biceps" name="RB" value=""][conditional field="RB" condition="(RB).is('')"]Right Biceps: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Left Biceps" name="LB" value=""][conditional field="LB" condition="(LB).is('')"]Left Biceps: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Right Triceps" name="RT" value=""][conditional field="RT" condition="(RT).is('')"]Right Triceps: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Left Triceps" name="LT" value=""][conditional field="LT" condition="(LT).is('')"]Left Triceps: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Right Forearm" name="RF" value=""][conditional field="RF" condition="(RF).is('')"]Right Forearm: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Left Forearm" name="LF" value=""][conditional field="LF" condition="(LF).is('')"]Left Forearm: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Right Patella" name="RP" value=""][conditional field="RP" condition="(RP).is('')"]Right Patella: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Left Patella" name="LP" value=""][conditional field="LP" condition="(LP).is('')"]Left Patella: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Right Ankle" name="RA" value=""][conditional field="RA" condition="(RA).is('')"]Right Ankle: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Left Ankle" name="LA" value=""][conditional field="LA" condition="(LA).is('')"]Left Ankle: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional]
Babinski: [select value="negative|postive"] [text]
The following other neurologic findings were found: [textarea default="none"]

RX HX:
[checkbox value="SSRIs:|Citalopram (Celexa)|Escitalopram (Lexapro)|Paroxetine (Paxil)|Fluoxetine (Prozac)|Fluvoxamine (Luvox)|Sertraline (Zoloft)||SNRIs:|Duloxetine (Cymbalta)|Venlafaxine (Effexor)||Serotonin Antagonists Reuptake Inhibitors:|Trazodone||Norepinephrine Reuptake Inhibitors:|Bupropion (Wellbutrin)|Wellbutrin SR|Wellbutrin XL||Tetracyclic Antidepressants:|Mirtazapine (Remeron)||Serotonin Modulators and Stimulators:|Vilazodone (Viibryd)|Vortioxetine (Trintellix)||Atypical Antipsychotics:|Risperidone (Risperdal)|Olanzapine (Zyprexa)|Quetiapine (Seroquel)|Ziprasidone (Geodon)|Aripiprazole (Abilify)|Paliparidone (Invega)|Lurasidone (latuda)|Clozaril (Clozapine||Typical Antipsychotics|Haloperidol (Haldol)|Chlorpromazine (Thorazine)|Loxapine (Loxitane)|Fluphenazine (Prolixin)|Perphenazine (Trilafon)||Mood Stabalizers|Lithium|Lamotrigine (Lamictal)|Valproic Acid (Depakote)|Carbamazepine (Tegretol)||Anxiolytics:|Clonazepam (Klonopin)|Diazepam (Valium)|Lorazepam (Ativan)|Alprazolam (Xanax)|Hydroxyzine (Vistaril)|Diphenhydramine (Benadryl)|Gabapentin (Neurontin)|Buspirone (Buspar)||ADHD Medications:|Short Acting:|Adderall (Dextroamphetamine Sulf-Saccharate)|Focalin (Dexmethylphenidate)|Vyvanse (Lisdexamfetamine)||Non Stimulant:|clonidine|Kapvay|Guanfacine (Intuniv, Tenex)|Atomoxetine (Straterra)||Intermediate and Long-Acting:|Adderall XR (Dextroamphetamine Sulf-Saccharate)|Focalin XR (Dexmethylophenidate)|MetadateCD/ER (Methylphenidate||Misc:||Folic Acid|Melatonin|Multivitamin|Metoprolol|Propranolol|Clonidine|Lisinopril|Albuterol|"]
[textarea rows="3"]
*Chief Complaint*
Date and Time of Service:
Patient is admitted to the IOP for other
quotes

*Interval History*
Patient remains SYMPTOM other.
Which is described asSEVERITY other
The patient notices that it is sometimes improved by Modifying factors other


CURRENT ENCOUNTER HX & CONTENT









Affect is
Mood is
Thought process presents as
Speech is
Gait is



PAST PSYCH HX

Substance/s misuse:
Past psychiatric diagnoses:
Abuse/Trauma:
Violence:
Legal History/issues:
Suicide/homicide attempts/gestures:
Prior Treatment or Therapy inpatient/outpatient:

Family/Significant other/social connectedness - family of origin -




Hobbies/Acitivities/Habits/Occupation


PAST/CURRENT MED HX



MSE
Appearance: ,,.
Behavior: ,,.
Attitude: .
Speech: ,,,,.
Mood reported as: ,inferred as-
Affect: quality: , , ,
Thought form: ,..
Thought content: ,.
Perception: .
Insight: .
Judgment: .
Cognition: .

PMH:

General Health and Strength:


Significant Childhood Illnesses:


Major Adult Illnesses or Chronic Illnesses:



Limitation of abilities:
--Hearing:

--Vision:
--Speech:

--Gait:

--Dexterity:

--Swallow:


Review of Systems:

--Constitutional: c/o . Denies: .

--Head: c/o . Denies .

--Eyes: c/o .. Denies .

--Ears: c/o . .

--Nose: c/o . Denies .

--Mouth and Throat: c/o . Denies .

--Neck: c/o . Denies .

--Cardiac: c/o . Denies .

--Vascular: c/o . Denies .

--Respiratory: c/o . Denies .

--Gastrointestinal: c/o . Denies

--Endocrine: c/o . Denies .

--Hematological/Lymphatic: c/o . Denies .

--Genitourinary: c/o . Denies

Reproductive (female): c/o . Denies . Gravida Para Abortus . LMP: .

Reproductive (male): c/o . Denies .

--Musculoskeletal: c/o . Denies .

--Integument:
c/o . Denies .

--Neurological: c/o . Denies .

--Psychiatric: c/o . Denies


--General Appearance:
LOC:
Gait:
Hygiene and Grooming:
Affect:
Nutrition:
Distress:

--HEENT:
HEAD: Saw on insepction: .
EYES: Saw on inspection: , Fundus: , Eyebrows: eyelids: sclera: , Conjuctiva: . Felt on Palpation: . Snellen: . Jaeger Chart: . Ichihara Chart:
EARS: Saw on inspection: . Felt On Palpation: . Weber Test: . Rinne Test:
Nose: Saw on inspection: , discharge: . Felt on palpation: Frontal Sinuses: Maxillary Sinuses: , Trans-illumination: ,
Mouth/Throat: Saw on inspection: Lips:
, Dental Caries: , Alignment: , Oropharynx: , Uvula: , Tonsils: , Tongue: , Gag Reflex: .

--NECK: Saw on inspection , Felt on palpation: . Lymph nodes: Aneterior Cervical: . Posterior Cervical:
Tosillar: Sub-mandibular:
Sub-Mental: Supraclavicular: . Heard on Auscultation: Bruit|No Bruit"]

--RESPIRATORY:

Cyanosis:

--CARDIOVASCULAR:
. JVP: , Heaves/Lifts: PMI:, ,

--MUSCULOSKELETAL:
--JOINTS:



[/conditional]

--GASTROINTESTINAL:
Long Version

--GENITOURINARY:
. Prostate:
PVR: .

--INTEGUMENTARY:
.
Wounds:

Rashes:

Scars:


--NEUROLOGIC:
Gait:
Rhomberg:
Rapid alternating movements:
Cranial nerves:
cranial nerves II-XII intact.
Sensation:
Strength:
Reflexes:
Right Biceps Left Biceps Right Triceps Left Triceps Right Forearm Left Forearm Right Patella Left Patella Right Ankle Left Ankle
Babinski:
The following other neurologic findings were found:

--General Appearance:
LOC:
Gait:
Hygiene and Grooming:
Affect:
Nutrition:
Distress:

--HEENT:
HEAD: Saw on insepction: .
EYES: Saw on inspection: , Fundus: , Eyebrows: eyelids: sclera: , Conjuctiva: . Felt on Palpation: . Snellen: . Jaeger Chart: . Ichihara Chart:
EARS: Saw on inspection: . Felt On Palpation: . Weber Test: . Rinne Test:
Nose: Saw on inspection: , discharge: . Felt on palpation: Frontal Sinuses: Maxillary Sinuses: , Trans-illumination: ,
Mouth/Throat: Saw on inspection: Lips:
, Dental Caries: , Alignment: , Oropharynx: , Uvula: , Tonsils: , Tongue: , Gag Reflex: .

--NECK: Saw on inspection , Felt on palpation: . Lymph nodes: Aneterior Cervical: . Posterior Cervical:
Tosillar: Sub-mandibular:
Sub-Mental: Supraclavicular: . Heard on Auscultation: Bruit|No Bruit"]

--RESPIRATORY:

Cyanosis:

--CARDIOVASCULAR:
. JVP: , Heaves/Lifts: PMI:, ,

--MUSCULOSKELETAL:
--JOINTS:



[/conditional]

--GASTROINTESTINAL:
Long Version

--GENITOURINARY:
. Prostate:
PVR: .

--INTEGUMENTARY:
.
Wounds:

Rashes:

Scars:


--NEUROLOGIC:
Gait:
Rhomberg:
Rapid alternating movements:
Cranial nerves:
cranial nerves II-XII intact.
Sensation:
Strength:
Reflexes:
Right Biceps Left Biceps Right Triceps Left Triceps Right Forearm Left Forearm Right Patella Left Patella Right Ankle Left Ankle
Babinski:
The following other neurologic findings were found:

RX HX:

Result - Copy and paste this output: