Amiodarone Monitoring (PharmD) WIP

Amiodarone Monitoring

Date initiated: [date name="variable_1" default="06-29-2023"]
Last filled date: [date name="variable_1" default="06-29-2023"]
Days' supply: [text name="variable_1" default="sample text"]
Adherence/compliance: [text name="variable_1" default="sample text"]
Daily dose >400mg?: [radio name="variable_1" value="yes|no"]
Any new medications, including over-the-counter drugs and supplements?
[radio name="variable_1" value="yes|no"]
Drug-drug interactions: 
[textarea name="variable_1" default="sample text"]

BP & HR Log:
[textarea name="variable_1" default="sample text"]
    BP goal: [text name="variable_1" default="sample text"]
    BP within goal?: [select name="variable_1" value="yes|no"]
    HR WNL?: [select name="variable_1" value="yes|no"] 

LFTs
[textarea name="variable_1" default="sample text"]
    LFTs WNL? [select name="variable_1" value="yes|no"]
    
Electrolytes
[textarea name="variable_1" default="sample text"]
    Electrolytes WNL? [select name="variable_1" value="yes|no"]

    
EKG 
    Date: [date name="variable_1" default="06-29-2023"]
    Results/Impression:
    [textarea name="variable_1" default="sample text"]
    
Thyroid 
    Date: [date name="variable_1" default="06-29-2023"]
    Performed within last 6 months?: [select name="variable_1" value="yes|no"]
    [textarea name="variable_1" default="sample text"]
    Thyroid WNL? [select name="variable_1" value="yes|no"]
    
CXR 
    Date: [date name="variable_1" default="06-29-2023"]
    Performed within past 6 months?: [select name="variable_1" value="yes|no"]
    Does patient have any underlying lung disease? [select name="variable_1" value="yes|no"]
    New or worsening non-productive cough?: [select name="variable_1" value="yes|no"]
    New or worsening dyspnea?: [select name="variable_1" value="yes|no"]
    New or worsening pleuritic pain?: [select name="variable_1" value="yes|no"]

Skin
    Date of last exam: [date name="variable_1" default="06-29-2023"]
    [textarea name="variable_1" default="sample text"]

Ophthalmic
    Date of last exam: [date name="variable_1" default="06-29-2023"]
    [textarea name="variable_1" default="sample text"]

CNS
    New or worsening peripheral neuropathy? 
    [select name="variable_1" value="yes|no"]
    New or worsening muscle weakness?
    [select name="variable_1" value="yes|no"]
    
Other    
    S/sx weight loss?: [select name="variable_1" value="yes|no"]
    S/sx edema?: [select name="variable_1" value="yes|no"]
Amiodarone Monitoring

Date initiated:
Last filled date:
Days' supply:
Adherence/compliance:
Daily dose >400mg?:
Any new medications, including over-the-counter drugs and supplements?

Drug-drug interactions:


BP & HR Log:

BP goal:
BP within goal?:
HR WNL?:

LFTs

LFTs WNL?

Electrolytes

Electrolytes WNL?


EKG
Date:
Results/Impression:


Thyroid
Date:
Performed within last 6 months?:

Thyroid WNL?

CXR
Date:
Performed within past 6 months?:
Does patient have any underlying lung disease?
New or worsening non-productive cough?:
New or worsening dyspnea?:
New or worsening pleuritic pain?:

Skin
Date of last exam:


Ophthalmic
Date of last exam:


CNS
New or worsening peripheral neuropathy?

New or worsening muscle weakness?


Other
S/sx weight loss?:
S/sx edema?:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.69, 35 form elements, 109 boilerplate words, 3 text boxes, 8 text areas, 7 dates, 2 radio buttons, 15 drop downs, 35 total clicks
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