[checklist value="Constitutional: No fevers, changes in weight, fatigue, night sweats|Head: No headache, sinus congestion or pain|Ears: No ear pain, discharge, hearing loss, tinnitus, vertigo|Eyes No changes in vision, eye pain, diplopia, photophobia, |Nose: No nasal discharge, coryza, sneezing, epistaxis |Throat: No cough, sore throat, dysphagia, odynophagia, |Skin: No diagnosed skin conditions, new lesions, rashes, discoloration, dryness, hair changes|Heme: No easy bruising, easy bleeding|CV: No chest pain, palpitations, edema, presyncope, decrease in exercise tolerance|Resp: No expectoration, dyspnea with rest or exertion, increased puffer use, orthopnea, PND, wheeze, |GI: No abdominal pain, nausea, vomiting, diarrhea, constipation, melena, appetite changes, dyspepsia, belching|GU: No dysuria, frequency, urgency, hematuria, nocturia, incontinence, dribbling, hesitancy, retention, flank pain|Male: Denies discharge, lesions, testicular pain, hernias|Female: Denies discharge, lesions, changes in dysmenorrhea, PMS, menstrual frequency, duration, flow, or symptoms|MSK: No new weakness, arthralgias, myalgias|Neuro: No weakness, confusion, numbness, dizziness, imbalance|Endocrine: No polydipsia, polyuria, heat/cold sensitivity|Pain: No new or unexplained pain|Psychology: No new or worsening depression, anxiety, or insomnia, stress, anger |Social: No change in home, relationships, employment, substance use, exercise, exposure|Function: No change in ADLs or IADLS, memory, capacity"]

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Sandbox Metrics: Structured Data Index 1, 1 form elements, 1 check lists, 21 total clicks
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