New Patient Referral Consult

[date name="Date"]

[textarea name="Patient name" memo="Patient Name" default="Patient Name" cols="8" rows="1"][text name="Date Of Birth" memo="Date Of Birth" default="Date Of Birth_______________________" size="20"]

[text name="Initial consult" memo="Initial Consult" default="Patient is a    year old    who presents to my office as a new patient for initial consultation for      this patient was referred to me by     for evaluation and treatment. " size="200"]
The patient is complaining of [text default="CHIEF COMPLAINT"] that began [text default="ONSET"][text default="CONTEXT"]. Symptoms have been [text default="TIMING"] since onset and is reported to be [text default="SEVERITY"] in severity. Patient reports the symptoms are located [text default="LOCATION"] and describes the quality as [text default="QUALITY"]. Symptoms associated with [text default="POSITIVE SYMPTOMS"] but denies any [text default="NEGATIVE SYMPTOMS"].

Symptoms are improved with [text default="MODIFYING FACTOR"] and exacerbated by [text default="MODIFYING FACTOR"]. Patient [text default="REPORTS/DENIES"] history of similar symptoms. Pertinent medical history includes [text default="PERTINENT PAST MEDICAL HISTORY"]. 
Patient adds [text default="OTHER DETAILS"].

[text name="Medication List" memo="Medication List" 
default="Medication List" size="10"]

[text name="Cardiologist " memo="Cardiologist " default="Cardiologist Name:____________________________ " size="20"][text name="Cardiologist " memo="Cardiologist " default="Last Cardiologist Visit:________________" size="20"]
[checkbox name="Blood Thinners" value="ASA|Plavix|Warfarin (Brand name: Coumadin)|Eliquis(Apixaban)|Pradaxa(Dabigatran)|Savaysa(Edoxaban)|Xarelto (Rivaroxaban)"]
[text name="Past Medical History" memo="Past Medical History" default="Past Medical History" size="1"]
[checkbox name="Past Medical History" value="Hypertension|HLD|Diabetic|Thyroid disorder   Hypo   Hyper|COPD|CHF|GERD|Osteoporosis|Hernia|Peptic Ulcer|Cancer|Anxiety|Depression|PTSD|GI Disorder|Stroke|Epilepsy|Arthritis|Other___________________________________________________"]



General:
[select name="" value="c/o of| "] [checkbox name="1" value=" | fatigue|fever|chills|malaise|generalized weakness|diffuse pain|sleeping problems|night sweats|weight changes"]
denies [checkbox name="356" value=" | fatigue|fever|chills|malaise|generalized weakness|diffuse pain|sleeping problems|night sweats|weight changes"]

Head:
[select name="" value="c/o of| "] [checkbox name="2" value=" |headaches|dizziness|syncope|dizziness|sinus pain|LOC"]. Denies [checkbox name="43" value=" |headaches|dizziness|syncope|dizziness|sinus pain|LOC"].


Neck: 
[select name="" value="c/o of| "] [checkbox name="11" value=" |neck pain|stiffness|edema|fullness|"] Denies [checkbox name="13" value=" |neck pain|stiffness|edema"] 

Cardiac: 
[select name="" value="c/o of| "] [checkbox name="15" 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"] . Denies [checkbox name="16" 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"].
[select name="" value="c/o of| "] [checkbox name="17" value=" |claudication|color changes in extremities|parathesias|coldness in extremities|tendency to bruise"] . Denies [checkbox name="18" value=" |claudication|color changes in extremities|parathesias|coldness in extremities"].

Respiratory:
[select name="" value="c/o of| "] [checkbox name="19" value=" |Pain with Respiration|Dyspnea|Cyanosis|Coughing|Wheezing|Sputum|Hemoptysis|Night Sweats|shortness of breath|exercise intolerance with activity"] . Denies [checkbox name="20" value=" |Pain with Respiration|Dyspnea|Cyanosis|Coughing|Wheezing|Sputum|Hemoptysis|Night Sweats|shortness of breath|exercise intolerance with activity"].

Gastrointestinal: 
[select name="" value="c/o of| "] [checkbox name="21" 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|dark black tarry stools|hemorrhoid"] . Denies[checkbox name="22" 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|
"] 


Hematological/Lymphatic: 
[select name="" value="c/o of| "] [checkbox name="25" value=" |anemia|purpura|petechia| prolonged or excessive bleeding after dental extraction/injury|bruising|blood clots|enlarged lymph nodes|tender lymph nodes"] . Denies [checkbox name="26" value=" |anemia|purpura|petechia| prolonged or excessive bleeding after dental extraction/injury|bruising|blood clots|enlarged lymph nodes|tender lymph nodes"].

Genitourinary:
[select name="" value="c/o of| "] [checkbox name="27" 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|Frequent Kidney Stones"] . Denies [checkbox name="28" 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"]


Musculoskeletal: 
[select name="" value="c/o of| "] [checkbox name="33" value=" |joint pain or tenderness|joint swelling|muscles pain|ROM changes|stiffness |bony deformity|misalignment"] . Denies [checkbox name="34" value=" |joint pain or tenderness|joint swelling|muscles pain|ROM changes|stiffness |bony deformity|misalignment"].

Integument:
[select name="" value="c/o of| "] [checkbox name="35" value=" |pruritis|rashes|stria|lesions|wounds|pigmentation changes|acanthosis nigricans|nodules|lumps/bumps|excessive dryness|discoloration|texture changes|eruptions"] . Denies [checkbox name="36" value=" |pruritis|rashes|stria|lesions|wounds|pigmentation changes|acanthosis nigricans|nodules|lumps/bumps|excessive dryness|discoloration|texture changes|eruptions"].


Breasts: 
[select name="" value="c/o of| "] [checkbox name="41" value=" |breast pain/soreness|Increasing in size|discharge|lumps|recent mammogram|recent biopsy"]
. Denies [checkbox name="42" value=" |breast pain/soreness|Increasing in size|discharge|lumps|recent mammogram|biopsy"]

OBJECTIVE

Vital signs: T[text name="55" default="sample text"] P[text name="56" default="sample text"] R[text name="57" default="sample text"] BP[text name="58" default="sample text"] 
Nurtition: Weight: [text name="61" default="sample text"] 

Appearance: [checkbox name="appearance" value="Well-appearing, well-nourished, NWOB|age-appropriate behavior||active, non-toxic|engages well|strong suck|crying|easily consoled||ill-appearing|tired-looking|diaphoretic|short of breath|sweating|cooperative with exam|poor cooperation with exam|agitated|anxious|appears sedated|appears impaired|disheveled|"] [textarea cols=40 rows=2]

Discomfort: [checkbox name="discomfort" value="no signs of discomfort visible while ambulating & getting on/off exam table|no signs of discomfort visible while sitting in chair||guarding|restlessness|sighing|crying|grimacing|verbal protests|"][textarea cols=40 rows=2]
Head: [checkbox name="head" value="Normocephalic, atraumatic|normal hair distributionnormal anterior fontanel||scalp tenderness|alopecia|swelling|"] [textarea cols=40 rows=2]



Neck: [checkbox name="neck" value="Symmetric with free painless ROM and no masses|supple|no LAD|no bruit or JVD||anterior LAD|posterior LAD|thyroid enlargement|nuchal tenderness|"] [textarea cols=40 rows=2]
Lungs: [checkbox name="lungs" value="Normal work of breathing, symmetrical chest expansion, no stridor audible|clear and equal breath sounds bilaterally||SOB|stridor|intercostals retractions|wheezing|crackles|breath sounds decreased bilaterally|"] [textarea cols=40 rows=2]
Chest/CV: [checkbox name="cv" value="Chest wall atraumatic and non-tender|no SOB, no ankle edema|regular rhythm, no murmurs|pedal skin warm with good & equal pulses||tachycardia|irregular hear rhythm|systolic murmur|calf tenderness|ankle edema|varicosities|stasis discoloration||no axillary or supraclavicular LAD|chest wall tenderness|sternal tenderness|breast mass|breast tenderness|skin dimpling/retraction|"] [textarea cols=40 rows=2]
Abdomen: [checkbox name="abd" value="Normal visual inspection, no distension|not examined|normal active bowel sounds|soft non-tender|no bruit auscultated over AA and renal arteries||protruding|surgical scar|diffuse tenderness over entire abdomen w/o RRG|umbilical hernia|abdominal striae|hypoactive bowel sounds|hyperactive bowel sounds|direct non-rebound tenderness|"] [textarea cols=40 rows=2]
GU: [checkbox name="gu" value="Not examined|no CVAT bilaterally|no suprapubic tenderness||normal external genitalia|circumcised|uncircumcised|no inguinal LAD|smooth non-tender testes|+cremasteric reflexes bil|no skin lesions|no urethral discharge|testicular tenderness|urethral discharge|verrucous papules|vesicles|crusted lesions|pearly penile papules"] [textarea cols=40 rows=2]

Upper extremity(s) [text] [checkbox name="upper_extremity" value="Atraumatic w/o swelling, atrophy or deformity|free and painless ROM|strength, tone, & bulk symmetrica & grossly intactl|able to make tight grips|no vascular compromise|compartments soft w/o tension||+ Appley scratch|+ painful arc|deltoid tenderness|bicipital groove tenderness|tenderness|swelling|ecchymosis|"] [textarea cols=40 rows=2]
Lower extremity(s) [text] [checkbox name="lower_extremity" value="Atraumatic w/o swelling, atrophy or deformity|free and painless ROM|strength, tone, & bulk symmetrical & grossly intact|able to raise/lower foot against resistance|no vascular compromise|compartments soft w/o tension||+ McMurray|DROM|tenderness|swelling|ecchymosis|"] [textarea cols=40 rows=2]


Skin: [checkbox name="skin" value="Grossly intact, no suspicious lesions, no rashes|no bruises|normal turgor||multiple tattoos|body piercings|poor turgor|dry|sweaty||"]
[textarea cols=40 rows=2] [checkbox name="single_lesion" value="erythema|induration|firm|soft|deep|mobile|fluctuant|painful|"]
[textarea cols=40 rows=2] [checkbox name="injury_wound" value="abrasion|excoriation|fissure|laceration|ulceration|ecchymosis|swelling|burn|scar|"]
[textarea cols=40 rows=2] [checkbox name="rash" value="generalized distribution|acral distribution|symmetrical|unilateral|linear|annular|arcuate|serpiginous|red scaly|red non-scaly|macular|popular|follicular|urticarial|targedoid|vesicular|pustular|purpuric|non-blanching|sharply-demarkated borders|indistinct borders|"] [textarea cols=40 rows=2]





Assessment/Plan


LABS

[textarea name="343435" default="sample text"]


Diagnosis:
[text name="633637" default="sample text"]

DDx:
[textarea name="837447" default="sample text"]
==============================================
PLAN: 

[textarea name="8333" default="sample text"]
[comment memo="Risk and benefit of surgery has been reviewed with patient and all questions have been answered."]