MOIMSD Care Plan

Current Visit Plan:
[textarea name="variable_12"]

Care Plan Objectives has been revised and updated on [date name="variable_1"date default="today"] as following:

1- Medical "Measurable Targets"
[checkbox name="variable_2" value="BMI<25|HBA1C<7|FBS: 80-130 mg/dl|BP <140/90|BP <130/80|LDL<100 mg/dl|All health parameters are within normal range|Other"]
[conditional field="variable_2" condition="(variable_2).is('Other')"][text name="variable_13"][/conditional]
2- Nutritional:
[checkbox name="variable_4" value="Low Salt Diet|Low Fat Diet|Diabetic Diet|Iron Rich Diet|Balanced Diet|Other"]
[conditional field="variable_4" condition="(variable_4).is('Other')"][text name="variable_14"][/conditional]
3- Education:
[checkbox name="variable_6" value="Nature of condition, Diagnosis and prognosis|Medications, frequancy, side effects & response to therapy|Diet & weight control|Physical Activity|Foot care|Smoking hazards|Healthy lifestyle|Other"]
[conditional field="variable_6" condition="(variable_6).is('Other')"][text name="variable_15"][/conditional]
4-Psychosocial:
- Need referral to social worker --> [select name="variable_8" value="No|Yes|"]
- Need referral to psychologist --> [select name="variable_9" value="No|Yes|"]

5- Referral to:
[checkbox name="variable_10" value="Ophthalmology Once/Year|Dental clinic Once/Year|Patient does not need referral|Other"]
[conditional field="variable_10" condition="(variable_10).is('Other')"][text name="variable_16"][/conditional]
6- Follow up: [text size="5"] [select value="|routine f/u visit not indicated|day(s)|week(s)|month(s)"]

7-Patient/Family involvement:
[checklist name="variable_11" value="Patient|Family"]
Current Visit Plan:


Care Plan Objectives has been revised and updated on as following:

1- Medical "Measurable Targets"


2- Nutritional:


3- Education:


4-Psychosocial:
- Need referral to social worker -->
- Need referral to psychologist -->

5- Referral to:


6- Follow up:

7-Patient/Family involvement:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.6, 19 form elements, 47 boilerplate words, 5 text boxes, 1 text areas, 1 dates, 4 checkboxes, 1 check lists, 3 drop downs, 4 conditionals, 38 total clicks
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