Patient Data

First Name: [text name="fname" default=""]
Last Name: [text name="lname" default=""]
Age: [text name="age" default=""]
Race: [text name="race" default=""]
Sex: [text name="sex" default=""]
Current City: [text name="currentcity" default=""]
Allergies: [text name="algy" default=""]
Primary Care Provider: [text name="currentpcp" default=""]



Caregiver

First Name: [text name="adult_fname" default=""]
Last Name: [text name="adult_lname" default=""]
Relationship to Patient: [text name="adult_id" default=""]

Referring Source
First Name: [text name="referring_fname" default=""]
Last Name: [text name="referring_lname" default=""]
Credentialing: [select name="referring_credential" value="LPC|LSW|LCSW|LMSW||CMHP|choice C"]

Chief Complaint:
[textarea name="cc" default=""]

General Medical History


Patient has an allergy to [PCN].
Patient is currently prescribed [medication].
Patient’s immunizations are up to date.
There are no reports of asthma, diabetes, hypothyroidism, TB, seasonal allergies or seizure.
There were no reports of any surgeries or hospitalizations.






Identifying Data/Chief Complaint: [var name="fname"] [var name="lname"] is a [var name="age"] year old [var name="race"] [var name="sex"] presenting for initial assessment and pharmacologic management of [var name="dx"]. Patient's [var name="adult_id"], [var name="adult_fname"] [var name="adult_lname"], brought [var name="fname"] for evaluation and lives in [var name="city"], [var name="state"]. Patient referred by [var name="refsource"] with a chief complaint of "[var name="cc"]".

History of Present Illness: [var name="fname"] [var name="lname"] is a [var name="age"] year old [var name="race"] [var name="sex"] presenting for initial assessment and pharmacologic management of [var name="dx"]. Patient's [var name="adult_id"], [var name="adult_fname"] [var name="adult_lname"], brought [var name="fname"] for evaluation and lives in [var name="city"], [var name="state"]. Patient was referred as mentioned with the above chief complaint. Symptoms first noticed by [var name="fname"]'s [var name="adult_id"] a

[race, sex, maritial statues] here for initial assessment and pharmacologic management of ADHD, [diagnosis]. He was brought by his [parent/guardian name] for evaluation and lives in [Monett Missouri]. Consent to medical evaluation via telemedicine verified. Patient was referred by [hospital/case manager/friend] with a chief complaint of "[in own words]".
History of Present Illness: [Name ] is a [age] year old [sex, maritial status] here for initial assessment and pharmacologic management of ADHD, [diagnosis]. He was brought by his [parent/guardian] for evaluation and lives in [Monett Missouri]. Patient was referred as mentioned with the above chief complaint. Parents first notice symptoms when patient was [age first symptoms] and these consisted of [initial symptoms]