[checkbox memo="Version A" name="A" value=""][conditional field="A" condition="(A).is('')"][textarea cols=80 rows=5 default="Symptoms include ***wheezing/daytime cough/nighttime cough/cough with exercise/shortness of breath/chest tightness*** *** nights per month *** days per month Triggers ***colds/irritants/allergies/exercise/weather changes*** In the last year: *** ER/UCC visit(s), *** hospitalization(s), *** oral steroid course(s), *** missed school day(s), *** missed parent work day(s) Barriers to taking medications: ***side effects/refusal/social concerns*** Inhaler use: lasts approximately ***weeks***, ***does/does not*** use a spacer Peak flow meter: range is *** Associated symptoms: ***iitchy, red eyes/stuffy nose/sneezing/chronic sore throat/post-nasal drip/eczema/GE reflux*** Associated symptoms are ***under/not under** good control. Exposures include ***smoke/pets/irritants/allergens*** Previous testing and evaluations include ***pulmonary function tests/subspecialist visit(s)/allergy testing***"][/conditional][checkbox memo="Version B" name="B" value=""][conditional field="B" condition="(B).is('')"]Asthma since age [text] The patient has experienced the following symptoms: [text default="coughing/wheezing/shortness of breath/chest tightness/sputum production/URI like symptoms/night time wakening/heartburn/sinusitis/no symptoms related to asthma"] The pattern of symptoms are [text default="perennial/seasonal/continual/episodic/nocturnal/exertional"] The onset of the symptoms started [text]. [textarea default="Symptoms daily/worsening/with exertion/only at night/has been present daily/has continued to become worse/is present only on exertion/is present only at night/*** days of the past week/month"] Triggering agents and past year's events: [text default="URI/mold/mite/cockroach/animal dander/pollen/smoke/perfume/chemicals/exercise"] Exacerbating factors: [text default="occupational exposure/emotional changes/drugs/foods/changes in weather/endocrine changes"] Home environment The home is heated by [select value="forced air heat|wood burning stove|steam heat|electric heat"] The bedroom [select value="has been made dust free|has not been made dust free"] The family is made up of [select value="smokers|nonsmokers|at least one smoker"] The family has [select value="a dog|a cat|a pet that may cause asthma to be worse|no animals"] in the [select value="home|sleeping area"] There have been [text] hospitalizations, [text] ER visits, and about [text] outpatient visits during the past year. The patient has required [select value="no intubation|intubation"] in the past. Current Management Peak flow meter [select value="is used correctly|is used, but needs to have more education|is not used"] Spacer [select value="is used correctly|is used, but needs to have more education|is not used"] Personal best peak flow was [text] Asthma Action Plan [select value="is needed|is used correctly|is used, but needs to have more education|is not used"][textarea cols=80 rows=5 default=""][/conditional]
There are 26 form elements.