Miscellaneous
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CC:
[checkbox name="CC" value="severe chronic pain |severe nausea |cancer |seizures/epilepsy |glaucoma |crohn's disease |PTSD |hepatitis C |HIV |AIDS |severe or persistent muscle spasms |cachexia or wasting syndrome |agitation of Alzheimer's disease |ALS"]

HPI:
Patient presents [select value="for an initial medical marijuana certification |for renewal of a medical marijuana certification previously obtained|for a medical marijuana consultation "][textarea default="for management of"]

SH:
Alcohol: [select value="none|rarely|occasionally or socially|frequently or daily"]
Comment: [text]
Tobacco: [select value="none|1/2 ppd or less|1/2 - 1ppd|1+ ppd|cigars|e-cigs or vape|chew / dip|pipe"]
Comment: [text]
Work: [select value="not working|retired|disabled|full time|part time|student|stay-at-home parent"]
Comment:[text]

VITALS:
BP: [text]
HR: [text]
HT: [text]
WT: [text]

GENERAL APPEARANCE
[checkbox value="no distress |lethargic |restless or jittery |thin |frail |overweight/obese"]

[checkbox memo="HEAD" checkbox name="HEAD"][conditional field="HEAD" condition="(HEAD).is('')"][textarea][/conditional]

[checkbox memo="CHEST & ABDOMEN" checkbox name="CHEST"]
[conditional field="CHEST" condition="(CHEST).is('')"] [textarea default="normal respiratory chest excursions"] [/conditional]

[checkbox memo="NECK & BACK" checkbox name="BACK"]
[conditional field="BACK" condition="(BACK).is('')"][textarea] [/conditional]

[checkbox memo="EXTREMITIES" checkbox name="EXT"]
[conditional field="EXT" condition="(EXT).is('')"][textarea default="pulses regular"][/conditional]
CC:


HPI:
Patient presents

SH:
Alcohol:
Comment:
Tobacco:
Comment:
Work:
Comment:

VITALS:
BP:
HR:
HT:
WT:

GENERAL APPEARANCE


HEAD

CHEST & ABDOMEN


NECK & BACK


EXTREMITIES

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