Paramedic Patient Assessment

DISPATCHED FOR:[textarea name="dispatch" default=" "]

RESPONSE:
[checkbox name="RESPONSE" value="EMERGENT.|NONEMERGENT.|LIGHTS/SIRENS.|LIGHTS NO SIRENS.|NO LIGHTS NO SIRENS.|UPGRADED TO EMERGENT.|DOWNGRADED TO NONEMERGENT."]

DISPATCH PRIORITY: 
[checkbox name="Alpha" value="A|B|C|D|E"]

DISPATCHED Level: 
[checkbox name="LEVEL" value="priority 1|priority 2|priority 3| priority 4| priority 5"]

Hospital Destination: [text name="Hospital Destination" default=" "]
Reason For Hospital Destinaton: [text name="Reason For Hospital Destination" default=" "]
===================================================================================

**************
* COVID - 19 *
**************

Close contact with person with confirmed or suspected COVID-19: [select name="variable_2" value="NO|YES"]
Travel to high risk COVID-19 areas per current local guidance: [select name="variable_3" value="NO|YES"]

SYMPTOMS:
Shortness of breath:[select name="variable_1" value="NO|YES"]
Cough: [select name="variable_2" value="NO|YES"]
Fever >100.4: [select name="variable_3" value="NO|YES"]
Sore Throat: [select name="variable_4" value="NO|YES"]
Loss of Smell: [select name="variable_5" value="NO|YES"]
Nausea: [select name="variable_6" value="NO|YES"]
Vomiting: [select name="variable_7" value="NO|YES"]
Flue like symptoms: [select name="variable_8" value="NO|YES"]
Onset of first symptom:[date name="variable_1" default="05/04/2020"]
Quarantine: [select name="Quarantineintiated" value="Yes |No"] 
Isolation: [select name="Isolationintiated" value="Yes |No"]

Symptoms are [select name="variable_1"name="variable_2"name="variable_3"name="variable_3"name=variable_4"name=variable_5"name=variable_5"name=variable_6"name="variable_7"name=variable_8" value="IMPROVING|WORSENING|STAYING THE SAME"] since onset.

**********************************************************************************
*** SUBJECTIVE ***
**********************************************************************************

===================================================================================
Arrived to find [text name="variable_1" default=" "] 
Gender [checkbox name="Gender" value="Male|Female|Refused to Answer"]
Age [text name="variable_1" default=" "]
===================================================================================
Patient complained of: [textarea name="The Patient complained of" default="sample text"]
Patient DENIED:[textarea name="The Patient denied the following:" default="sample text"]
Patient's Medical History: [textarea name="The Patient's Medical History is" default="sample text"]
Patient's Allergies: [textarea name="The Patient's Allergies are" default="sample text"]
Patient's Medications: [textarea name="The Patient's Medications are" default="sample text"] 
===================================================================================
Onset: [text name="Onset:" default="sample text"]
Location: [text name="Location:" default="sample text"]
Duration:[text name="Duration:" default="sample text"]
Characterization:[text name="Characterization:" default="sample text"]
Alleviating and Aggravating Factors:[text name="Alleviating and Aggravating Factors default="sample text"]
Radiation:[text name="Radiation" default="sample text"]
Time:[text name="Time" default="sample text"]
Severity:[text name="Severity" default="sample text"]

===================================================================================

Admits or Denies 

Headache[select name="variable_1" value="NO|YES"]
Dizziness[select name="variable_1" value="NO|YES"]
Blurred Vision[select name="variable_1" value="NO|YES"]
Nausea[select name="variable_1" value="NO|YES"]
Vomiting[select name="variable_1" value="NO|YES"]
Diarrhea[select name="variable_1" value="NO|YES"]
Chest Pain[select name="variable_1" value="NO|YES"]
Difficulty Breathing[select name="variable_1" value="NO|YES"]
Abdominal Pain[select name="variable_1" value="NO|YES"]
Pelvic Pain[select name="variable_1" value="NO|YES"] 
Leg Pain[select name="variable_1" value="NO|YES"]
Arm Pain[select name="variable_1" value="NO|YES"]
Back Pain[select name="variable_1" value="NO|YES"]
Neck Pain[select name="variable_1" value="NO|YES"]
LOC[select name="variable_1" value="NO|YES"]
Alcoholic Beverages[select name="variable_1" value="NO|YES"] 
Recreational Drugs[select name="variable_1" value="NO|YES"] 
Pregnancy[select name="variable_1" value="NO|YES"] 
Foreign Travel[select name="variable_1" value="NO|YES"] 
Recent Illness[select name="variable_1" value="NO|YES"]
Recent Trauma[select name="variable_1" value="NO|YES"]
Recent Surgery[select name="variable_1" value="NO|YES"]

===================================================================================
==  Objective  ==
===================================================================================

ABC'S 

Airway: 
[checkbox name="variable_1" value="Patent|Compromised|Obstructed"]

Breathing: 
---Regularity
[checkbox name="variable_1" value="Regular|Irregular|Agonal|Apneic"]
---Rate
[checkbox name="variable_1" value="Normal|Fast|Slow"]
---Depth
[checkbox name="variable_1" value="Normal|Shallow|Deep"]
---Effort 
[checkbox name="variable_1" value="Without Effort|With Effort"]

Circulation:
Skin:
[checkbox name="variable_1" value="Pink|Pale|Cyanotic|Jaundice|Lividity|Mottled"]
DISPATCHED FOR:

RESPONSE:


DISPATCH PRIORITY:


DISPATCHED Level:


Hospital Destination:
Reason For Hospital Destinaton:
===================================================================================

**************
* COVID - 19 *
**************

Close contact with person with confirmed or suspected COVID-19:
Travel to high risk COVID-19 areas per current local guidance:

SYMPTOMS:
Shortness of breath:
Cough:
Fever >100.4:
Sore Throat:
Loss of Smell:
Nausea:
Vomiting:
Flue like symptoms:
Onset of first symptom:
Quarantine:
Isolation:

Symptoms are since onset.

**********************************************************************************
*** SUBJECTIVE ***
**********************************************************************************

===================================================================================
Arrived to find
Gender
Age
===================================================================================
Patient complained of:
Patient DENIED:
Patient's Medical History:
Patient's Allergies:
Patient's Medications:
===================================================================================
Onset:
Location:
Duration:
Characterization:
Alleviating and Aggravating Factors:
Radiation:
Time:
Severity:

===================================================================================

Admits or Denies

Headache
Dizziness
Blurred Vision
Nausea
Vomiting
Diarrhea
Chest Pain
Difficulty Breathing
Abdominal Pain
Pelvic Pain
Leg Pain
Arm Pain
Back Pain
Neck Pain
LOC
Alcoholic Beverages
Recreational Drugs
Pregnancy
Foreign Travel
Recent Illness
Recent Trauma
Recent Surgery

===================================================================================
== Objective ==
===================================================================================

ABC'S

Airway:


Breathing:
---Regularity

---Rate

---Depth

---Effort


Circulation:
Skin:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.72, 64 form elements, 140 boilerplate words, 12 text boxes, 6 text areas, 1 dates, 10 checkboxes, 35 drop downs, 95 total clicks
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