Miscellaneous
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[checkbox memo="Constitutional/General" name="symp_const" value=""][conditional field="symp_const" condition="(symp_const).is('')"]
Confirms: [checkbox name="symp_Constitutional_confirms" value=" fatigue|fever|chills|malaise|generalized weakness|diffuse pain|sleeping problems|night sweats|weight changes"]
Denies: [checkbox name="symp_Constitutional_denies" value=" fatigue|fever|chills|malaise|generalized weakness|diffuse pain|sleeping problems|night sweats|weight changes"]
[/conditional]
[checkbox memo="Head" name="symp_head" value=""][conditional field="symp_head" condition="(symp_head).is('')"]
Confirms: [checkbox name="symp_head_confirms" value="headaches|dizziness|syncope|sinus pain|LOC"]
Denies: [checkbox name="symp_head_denies" value="headaches|dizziness|syncope|sinus pain|LOC"]
[/conditional]
[checkbox memo="Eyes" name="symp_eyes" value=""][conditional field="symp_eyes" condition="(symp_eyes).is('')"]
Confirms: [checkbox name="symp_eyes_confirms" value="vision loss|blurriness|blind spots|floaters|diplopia|photophobia|eye pain|halos|erythemia|drainage|change in appearance|dryness"]
Denies: [checkbox name="symp_eyes_denies" value="vision loss|blurriness|blind spots|floaters|diplopia|photophobia|eye pain|halos|erythemia|drainage|change in appearance|dryness"]
[/conditional]
[checkbox memo="Ears" name="symp_ears" value=""][conditional field="symp_ears" condition="(symp_ears).is('')"]
Confirms: [checkbox name="symp_ears_confirms" value="ear pain|tinnitus|hearing loss|fullness in ears|drainage|drainage|vertigo|frequent infections"]
Denies: [checkbox name="symp_ears_denies" value="ear pain|tinnitus|hearing loss|fullness in ears|drainage|drainage|vertigo|frequent infections"]
[/conditional]
[checkbox memo="Nose,Mouth, and Throat" name="symp_nmt" value=""][conditional field="symp_nmt" condition="(symp_nmt).is('')"]
Confirms: [checkbox name="symp_nose_confirms" value="loss of smell|obstruction|epistaxis|drainage|congestion|tenderness|sinus pain|lesions"]
Denies: [checkbox name="symp_nose_denies" value="loss of smell|obstruction|epistaxis|drainage|congestion|tenderness|sinus pain|lesions"]
Confirms: [checkbox name="symp_mouth_confirms" 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"]
Denies: [checkbox name="symp_mouth_denies" 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"]
[/conditional]
[checkbox memo="Skin" name="symp_skin" value=""][conditional field="symp_skin" condition="(symp_skin).is('')"]
Confirms: [checkbox name="symp_skin_confirms" value="diagnosed skin conditions|new lesions|rashes|discoloration|dryness|hair changes"]
Denies: [checkbox name="symp_skin_denies" value="diagnosed skin conditions|new lesions|rashes|discoloration|dryness|hair changes"]
[/conditional]
[checkbox memo="Neck" name="symp_neck" value=""][conditional field="symp_neck" condition="(symp_neck).is('')"]
Confirms: [checkbox name="symp_neck_confirms" value="neck pain|stiffness|edema"]
Denies: [checkbox name="symp_neck_denies" value="neck pain|stiffness|edema"]
[/conditional]
[checkbox memo="Cardiac" name="symp_cardiac" value=""][conditional field="symp_cardiac" condition="(symp_cardiac).is('')"]
Confirms: [checkbox name="symp_cardiac_confirms" 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="symp_cardiac_denies" 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"]
Confirms: [checkbox name="symp_cardiac2_confirms" value="claudication|color changes in extremities|parathesias|coldness in extremities|tendency to bruise"]
Denies: [checkbox name="symp_cardiac2_denies" value="claudication|color changes in extremities|parathesias|coldness in extremities"]
[/conditional]
[checkbox memo="Respiratory" name="symp_resp" value=""][conditional field="symp_resp" condition="(symp_resp).is('')"]
Confirms: [checkbox name="symp_resp_confirms" value="Pain with Respiration|Dyspnea|Cyanosis|Coughing|Wheezing|Sputum|Hemoptysis|Night Sweats|shortness of breath|exercise intolerance with activity"]
Denies: [checkbox name="symp_resp_denies" value="Pain with Respiration|Dyspnea|Cyanosis|Coughing|Wheezing|Sputum|Hemoptysis|Night Sweats|shortness of breath|exercise intolerance with activity"]
[/conditional]
[checkbox memo="Gastrointestinal" name="symp_gastro" value=""][conditional field="symp_gastro" condition="(symp_gastro).is('')"]
Confirms: [checkbox name="symp_gastro_confirms" 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"]
Denies: [checkbox name="symp_gastro_denies" 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"]
[/conditional]
[checkbox memo="Endocrine" name="symp_endo" value=""][conditional field="symp_endo" condition="(symp_endo).is('')"]
Confirms: [checkbox name="symp_endo_confirms" 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"]
Denies: [checkbox name="symp_endo_denies" 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"]
[/conditional]
[checkbox memo="Hematological/Lymphatic" name="symp_hema" value=""][conditional field="symp_hema" condition="(symp_hema).is('')"]
Confirms: [checkbox name="symp_hema_confirms" value="anemia|purpura|petechia| prolonged or excessive bleeding after dental extraction/injury|bruising|blood clots|enlarged lymph nodes|tender lymph nodes"]
Denies: [checkbox name="symp_hema_denies" value="anemia|purpura|petechia| prolonged or excessive bleeding after dental extraction/injury|bruising|blood clots|enlarged lymph nodes|tender lymph nodes"]
[/conditional]
[checkbox memo="Genitourinary" name="symp_gent" value=""][conditional field="symp_gent" condition="(symp_gent).is('')"]
Confirms: [checkbox name="symp_gastro_confirms" 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"]
Denies: [checkbox name="symp_gastro_denies" 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"]
[/conditional]
[checkbox memo="Reproductive (female)" name="symp_repro_f" value=""][conditional field="symp_repro_f" condition="(symp_repro_f).is('')"]
Confirms: [checkbox name="symp_repro_f_confirms" 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"]
Denies: [checkbox name="symp_repro_f_denies" 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 (been pregnant):
Para (Full Term):
Premature Births:
Abortus (Non Viable pregnancies):
Last Mestral Period:
Pregnant: [select name="symp_female1_prego" value="No=1|Maybe=2|Yes=3"]
[/conditional]
[checkbox memo="Reproductive (male)" name="symp_repro_m" value=""][conditional field="symp_repro_m" condition="(symp_repro_m).is('')"]
Confirms: [checkbox name="symp_repro_m_confirms" value="difficulty with erection|difficulty with sexual arousal|lack of stamina|difficulty with emissions|testicular pain|hernias"]
Denies: [checkbox name="symp_repro_m_denies" value="difficulty with erection|difficulty with sexual arousal|lack of stamina|difficulty with emissions|testicular pain|hernias"]
[/conditional]
[checkbox memo="Musculoskeletal" name="symp_musk" value=""][conditional field="symp_musk" condition="(symp_musk).is('')"]
Confirms: [checkbox name="symp_musk_confirms" value="joint pain or tenderness|joint swelling|muscles pain|ROM changes|stiffness |bony deformity|misalignment"]
Denies: [checkbox name="symp_musk_denies" value="joint pain or tenderness|joint swelling|muscles pain|ROM changes|stiffness |bony deformity|misalignment"]
[/conditional]
[checkbox memo="Integument" name="symp_inte" value=""][conditional field="symp_inte" condition="(symp_inte).is('')"]
Confirms: [checkbox name="symp_inte_confirms" value="pruritis|rashes|stria|lesions|wounds|pigmentation changes|acanthosis nigricans|nodules|lumps/bumps|excessive dryness|discoloration|texture changes|eruptions"]
Denies: [checkbox name="symp_inte_denies" value="pruritis|rashes|stria|lesions|wounds|pigmentation changes|acanthosis nigricans|nodules|lumps/bumps|excessive dryness|discoloration|texture changes|eruptions"]
[/conditional]
[checkbox memo="Neurological" name="symp_neuro" value=""][conditional field="symp_neuro" condition="(symp_neuro).is('')"]
Confirms: [checkbox name="symp_neuro_confirms" 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"]
Denies: [checkbox name="symp_neuro_denies" 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"]
[/conditional]
[checkbox memo="Psychiatric" name="symp_psych" value=""][conditional field="symp_psych" condition="(symp_psych).is('')"]
Confirms: [checkbox name="symp_psych_confirms" 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"]
Denies: [checkbox name="symp_psych_denies" 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"]
[/conditional]
[checkbox memo="Social" name="symp_social" value=""][conditional field="symp_social" condition="(symp_social).is('')"]
Confirms: [checkbox name="symp_social_confirms" value="change in home|relationships|employment|substance use|exercise|exposure"]
Denies: [checkbox name="symp_social_denies" value="change in home|relationships|employment|substance use|exercise|exposure"]
[/conditional]
[checkbox memo="Function" name="symp_funct" value=""][conditional field="symp_funct" condition="(symp_funct).is('')"]
Confirms: [checkbox name="symp_funct_confirms" value="change in activities of daily living|memory|capacity"]
Denies: [checkbox name="symp_funct_denies" value="change in activities of daily living|memory|capacity"]
[/conditional]
[checkbox memo="Breasts" name="symp_breast" value=""][conditional field="symp_breast" condition="(symp_breast).is('')"]
Confirms: [checkbox name="symp_breast_confirms" value="breast pain/soreness|discharge|lumps"]
Denies: [checkbox name="symp_breast_denies" value="breast pain/soreness|discharge|lumps"]
[/conditional]
Constitutional/General
Head
Eyes
Ears
Nose,Mouth, and Throat
Skin
Neck
Cardiac
Respiratory
Gastrointestinal
Endocrine
Hematological/Lymphatic
Genitourinary
Reproductive (female)
Reproductive (male)
Musculoskeletal
Integument
Neurological
Psychiatric
Social
Function
Breasts

Result - Copy and paste this output: