S:
Date of injury/illness: [date name="variable_1" default="01/05/2019"]
C/o [textarea name="variable_1" default="sample text"]
HX of concussion:[checkbox name="variable_1" value="yes |no |unknown"]
Headache History? [checkbox name="variable_1" value="yes |no |unknown"]
Developmental History [text name="variable_1" default="sample text"]
Developmental History [text name="variable_1" default="sample text"]
O:
Is there evidence of a forcible blow to the head? [checkbox name="variable_1" value="direct |indirect|Unknown"]
Is there evidence of intracranial injury or skull fracture? [checkbox name="variable_1" value="Yes|No |Unsure"]
Location of Impact: [text name="variable_1" default="sample text"]
Cause: [radio name="variable_1" value=" MVC|Athletics|Assault| Fall"]
Amnesia Before (Retrograde) Are there any events just BEFORE the injury that you/ person has no memory of (even brief)? [checkbox name="variable_1" value="Yes|No |Unsure"]
Amnesia After S (Anterograde) Are there any events just AFTER the injury that you/ person has no memory of (even brief)?[checkbox name="variable_1|" value="Yes|No |Unsure|No Duration"]
Loss of Consciousness: Did the athlete lose consciousness? [checkbox name="variable_1" value="Yes|No |Unsure |No Duration"]
EARLY SIGNS: [checkbox name="variable_1" |Appears dazed or stunned |Is confused about events |Answers questions slowly | Repeats Questions |Forgetful|Value="dizziness|LOC|Balance problems"][checkbox name="Conussion" value="Slow reaction time|amnesia|sleep disturbance"][checkbox name="field_name" value="headaches|irritability|nausea"][checkbox name="field_name" value="vomiting|light sensativity|balance problems"]
Seizures: Were seizures observed? [checkbox name="variable_1" value="yes |no |unknown"] Detail [textarea name="variable_1" default="sample text"]
A:
[checkbox name="variable_1" value="850.0 (Concussion, with no loss of consciousness) – Positive injury description with evidence of forcible direct/ indirect blow to the head (A1a); plus
evidence of active symptoms (B) of any type and number related to the trauma (Total Symptom Score >0); no evidence of LOC (A5), skull fracture or
intracranial injury (A1b).|850.1 (Concussion, with brief loss of consciousness < 1 hour) – Positive injury description with evidence of forcible direct/ indirect blow to the head
(A1a); plus evidence of active symptoms (B) of any type and number related to the trauma (Total Symptom Score >0); positive evidence of LOC (A5),
skull fracture or intracranial injury (A1b|850.9 (Concussion, unspecified) – Positive injury description with evidence of forcible direct/ indirect blow to the head (A1a); plus evidence of active
symptoms (B) of any type and number related to the trauma (Total Symptom Score >0); unclear/unknown injury details; unclear evidence of LOC (A5), no
skull fracture or intracranial injury|Other Diagnoses – If the patient presents with a positive injury description and associated symptoms, but additional evidence of intracranial injury (A 1b)
such as from neuroimaging, a moderate TBI and the diagnostic category of 854 (Intracranial injury) should be considered"]
p:[textarea name="variable_1" default="sample text"]
Date of injury/illness: [date name="variable_1" default="01/05/2019"]
C/o [textarea name="variable_1" default="sample text"]
HX of concussion:[checkbox name="variable_1" value="yes |no |unknown"]
Headache History? [checkbox name="variable_1" value="yes |no |unknown"]
Developmental History [text name="variable_1" default="sample text"]
Developmental History [text name="variable_1" default="sample text"]
O:
Is there evidence of a forcible blow to the head? [checkbox name="variable_1" value="direct |indirect|Unknown"]
Is there evidence of intracranial injury or skull fracture? [checkbox name="variable_1" value="Yes|No |Unsure"]
Location of Impact: [text name="variable_1" default="sample text"]
Cause: [radio name="variable_1" value=" MVC|Athletics|Assault| Fall"]
Amnesia Before (Retrograde) Are there any events just BEFORE the injury that you/ person has no memory of (even brief)? [checkbox name="variable_1" value="Yes|No |Unsure"]
Amnesia After S (Anterograde) Are there any events just AFTER the injury that you/ person has no memory of (even brief)?[checkbox name="variable_1|" value="Yes|No |Unsure|No Duration"]
Loss of Consciousness: Did the athlete lose consciousness? [checkbox name="variable_1" value="Yes|No |Unsure |No Duration"]
EARLY SIGNS: [checkbox name="variable_1" |Appears dazed or stunned |Is confused about events |Answers questions slowly | Repeats Questions |Forgetful|Value="dizziness|LOC|Balance problems"][checkbox name="Conussion" value="Slow reaction time|amnesia|sleep disturbance"][checkbox name="field_name" value="headaches|irritability|nausea"][checkbox name="field_name" value="vomiting|light sensativity|balance problems"]
Seizures: Were seizures observed? [checkbox name="variable_1" value="yes |no |unknown"] Detail [textarea name="variable_1" default="sample text"]
A:
[checkbox name="variable_1" value="850.0 (Concussion, with no loss of consciousness) – Positive injury description with evidence of forcible direct/ indirect blow to the head (A1a); plus
evidence of active symptoms (B) of any type and number related to the trauma (Total Symptom Score >0); no evidence of LOC (A5), skull fracture or
intracranial injury (A1b).|850.1 (Concussion, with brief loss of consciousness < 1 hour) – Positive injury description with evidence of forcible direct/ indirect blow to the head
(A1a); plus evidence of active symptoms (B) of any type and number related to the trauma (Total Symptom Score >0); positive evidence of LOC (A5),
skull fracture or intracranial injury (A1b|850.9 (Concussion, unspecified) – Positive injury description with evidence of forcible direct/ indirect blow to the head (A1a); plus evidence of active
symptoms (B) of any type and number related to the trauma (Total Symptom Score >0); unclear/unknown injury details; unclear evidence of LOC (A5), no
skull fracture or intracranial injury|Other Diagnoses – If the patient presents with a positive injury description and associated symptoms, but additional evidence of intracranial injury (A 1b)
such as from neuroimaging, a moderate TBI and the diagnostic category of 854 (Intracranial injury) should be considered"]
p:[textarea name="variable_1" default="sample text"]
Result - Copy and paste this output: