Provider Initial Encounter Template

Patient Name [text name="variable_1" default="BS A/F"]
Patient DOB [text name="variable_1" default="BS A/F"]
Patient Preferred Language [text name="variable_1" default="BS A/F"]
Patient Location: [select name="variable_1" value="Home|Work|Other"]
Address: [text name="variable_1" default="BS A/F"]
Session Number [text name="variable_1" default="BS A/F"]

[checkbox name="variable_2" value="No barriers to communication identified"]

ID: [text name="variable_1" default="BS A/F"]

Cheif Complaint:
[textarea name="variable_1" default="AI A/F"]

History of Present Illness:
[textarea name="variable_1" default="AI A/F"]

Psychiatric History:
Previous Suicide Attempts: [text name="variable_1" default="BS A/F"]
Past Psychotropic Medications: [text name="variable_1" default="BS A/F"]
Previous Medication Trials: [text name="variable_1" default="BS A/F"]
Currently in Therapy: [text name="variable_1" default="BS A/F"]
Experience with Therapy: [text name="variable_1" default="BS A/F"]
Patient Name
Patient DOB
Patient Preferred Language
Patient Location:
Address:
Session Number



ID:

Cheif Complaint:


History of Present Illness:


Psychiatric History:
Previous Suicide Attempts:
Past Psychotropic Medications:
Previous Medication Trials:
Currently in Therapy:
Experience with Therapy:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.13, 15 form elements, 36 boilerplate words, 11 text boxes, 2 text areas, 1 checkboxes, 1 drop downs, 15 total clicks
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