Headache history draft

Headache
Location: [text]
Onset [text] prior to evaluation
Triggers:  [text]

Associated Pain: 
[checklist name="variable_1" value="jaw|neck|ear|eyes|teeth"]

Radiation: [text]
Severity now (0-10): [select name="severity" value="1|2|3|4|5|6|7|8|9|10|"]
Severity at worst (0-10): [select name="severity" value="1|2|3|4|5|6|7|8|9|10|"]
Duration: [text]
Characterized as:
[checklist name="variable_1" value="dull|aching| pressing|squeezing|pressing|sharp|shooting|electrical|burning|throbbing/pulsating"]

Pain modifiers
Relieved with [text]
Worse with [text]

Characteristics
[select value="no|YES"] <-- Pulsating or throbbing.
[select value="no|YES"] <-- Unilateral.
[select value="no|YES"] <-- moderate to severe.
[select value="no|YES"] <-- aggravated by exertion  or activity or avoidance of activity.
[select value="no|YES"] <-- light sensitivity. 
[select value="no|YES"] <-- sound sensitivity.
[select value="no|YES"] <-- Nausea and/or vomiting. 
[select value="no|YES"] <-- preceding aura before the headache (e.g. vision change, scotomata)
[select value="no|YES"] <-- blurred vision
[select value="no|YES"] <-- fever
[select value="no|YES"] <-- sinus pressure or nasal drainage
[select value="no|YES"] <-- extremity weakness
[textarea memo="details"]

Impact
[select value="no|YES"] <-- missed days of work or school 
[select value="no|YES"] <-- missed life events
[select value="no|YES"] <-- avoidance of activities
[select value="no|YES"] <-- emergency room visits
[textarea memo="details"]

Pertinent PMH
[select value="no|YES"] <-- Migraine Headache
[select value="no|YES"] <-- frequent Sinusitis
[select value="no|YES"] <-- Glaucoma
[select value="no|YES"] <-- Head Trauma
[select value="no|YES"] <-- Serious CNS risks (e.g. active cancer, immunosuppression, HIV)
[select value="no|YES"] <-- Exposures (e.g. Tick bites, carbon monoxide)
[textarea memo="details"]

[select value="no|YES"] <-- Family history of cerebral aneurysm or stroke

[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="http://www.fpnotebook.com" memo="website"][/conditional]
Headache
Location:
Onset prior to evaluation
Triggers:

Associated Pain:


Radiation:
Severity now (0-10):
Severity at worst (0-10):
Duration:
Characterized as:


Pain modifiers
Relieved with
Worse with

Characteristics
<-- Pulsating or throbbing.
<-- Unilateral.
<-- moderate to severe.
<-- aggravated by exertion or activity or avoidance of activity.
<-- light sensitivity.
<-- sound sensitivity.
<-- Nausea and/or vomiting.
<-- preceding aura before the headache (e.g. vision change, scotomata)
<-- blurred vision
<-- fever
<-- sinus pressure or nasal drainage
<-- extremity weakness
details

Impact
<-- missed days of work or school
<-- missed life events
<-- avoidance of activities
<-- emergency room visits
details

Pertinent PMH
<-- Migraine Headache
<-- frequent Sinusitis
<-- Glaucoma
<-- Head Trauma
<-- Serious CNS risks (e.g. active cancer, immunosuppression, HIV)
<-- Exposures (e.g. Tick bites, carbon monoxide)
details

<-- Family history of cerebral aneurysm or stroke

display/hide references

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.74, 40 form elements, 165 boilerplate words, 7 text boxes, 3 text areas, 1 checkboxes, 2 check lists, 25 drop downs, 1 links, 1 conditionals, 51 total clicks
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