Fall or Syncopal Episode
Onset [text] prior to evaluation
Onset while: [text]

Episode location: [text]
Episode description: [text].

Last similar episode: [text]

[select value="no|YES"] <-- remembers the episode
[select value="no|YES"] <-- remembers after the episode

Episode was preceded by the following symptoms that lasted [text]:
[select value="no|YES"] <-- lightheadedness
[select value="no|YES"] <-- palpitations
[select value="no|YES"] <-- chest pain
[select value="no|YES"] <-- nausea or vomiting
[select value="no|YES"] <-- headache
[select value="no|YES"] <-- abodominal pain
[select value="no|YES"] <-- visual changes

Episode was witnessed by [text] and they reported:
[select value="no|YES"] <-- complete loss of consciousness for a duration of [text]
[select value="no|YES"] <-- Seizure activity
[select value="no|YES"] <-- Confusion following the episode
[select value="no|YES"] <-- associated incontinence of urine or stool
[select value="no|YES"] <-- associated apnea
[select value="no|YES"] <-- associated pulselessness
[select value="no|YES"] <-- associated low blood sugar
[select value="no|YES"] <-- extremity weakness

PMH:
[select value="no|YES"] <-- Recent trauma
[select value="no|YES"] <-- Seizure history
[select value="no|YES"] <-- Diabetes Mellitus history
[select value="no|YES"] <-- Coronary Artery Disease history
[select value="no|YES"] <-- Cerebrovascular Accident history
[select value="no|YES"] <-- Gastrointestinal bleeding history
[select value="no|YES"] <-- Infection history or symptoms (e.g. UTI or pneumonia)
[select value="no|YES"] <-- Other (e.g. pregnancy in women of child bearing age)

Associated Injuries: [text]
[checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"]
reference: contributed by Dr. Scott Moses, creator/author of the Family Practice Notebook [link url="//www.fpnotebook.com" memo="(link)"][/conditional]