Subjective/History Elements
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-Symptoms-[checkbox value="watery runny nose|frequent sneezing|nasal blockage/stuffiness|itchy nose|Watery/red/itchy eyes|itchy throat|lump in throat (globus sensation)"]
-Worst/most-bothersome symptom- [select value="watery runny nose|frequent sneezing|nasal blockage/stuffiness|itchy nose|Watery/red/itchy eyes|itchy throat|lump in throat (globus sensation)"]
-Onset- [text size="3"] [select value="months|years"] ago
-Frequency of symptoms- [text size="20"]
-How bothersome symptoms are to patient? - [text size="3"]/7
[comment memo="Severity scale explanation:
1= None- occasional limited episode
3= Mildly bothersome- steady symptoms but easily tolerable
5= Moderately bothersome- symptoms hard to tolerate, may interfere with daily activities and/or sleep
7= Unbearably severe- symptoms are so bad, person can't function all the time" memo_size="small"]
-Symptom Triggers-
[select value="no|YES"]<-Pollen from trees, flowers and grasses
[select value="no|YES"]<-Mold (both indoors and outdoors)
[select value="no|YES"]<-Furred animals (especially cats, dogs and mice)
[select value="no|YES"]<-Dust mites
[select value="no|YES"]<-Specific seasons
[select value="no|YES"]<-Weather/temperature changes (esp. cold temperatures)
[select value="no|YES"]<-Tobacco smoke
[select value="no|YES"]<-Strong fumes (ie. vehicle exhaust or chemicals)
[select value="no|YES"]<-Perfumes
[select value="no|YES"]<-Spicy foods (more than just mild runny nose)
[select value="no|YES"]<-Other allergens: [text size="50"]
-Current treatment(s)-
[checkbox value="none"][checkbox memo="(ie. claritin/allegra/zyrtec)" memo_size="small" value="oral antihistamine"][checkbox memo="(ie. flonase/nasonex)" memo_size="small" value="intranasal steroids"][checkbox memo="(ie. astelin/patanase)" memo_size="small" value="intranasal antihistamine"][checkbox memo="(ie. sudaphed or phenyleprhine)" memo_size="small" value="oral decongestant"][checkbox memo="(ie. afrin/neosynephrine" memo_size="small" value="intranasal decongestant"][checkbox value="intranasal capsaicin"][checkbox value="nasal rinse kit"]. [text memo="other treatments if any" size="50"]
-Prior treatment(s)
[checkbox value="none"][checkbox memo="(ie. claritin/allegra/zyrtec)" memo_size="small" value="oral antihistamine"][checkbox memo="(ie. flonase/nasonex)" memo_size="small" value="intranasal steroids"][checkbox memo="(ie. astelin/patanase)" memo_size="small" value="intranasal antihistamine"][checkbox memo="(ie. sudaphed or phenyleprhine)" memo_size="small" value="oral decongestant"][checkbox memo="(ie. afrin/neosynephrine" memo_size="small" value="intranasal decongestant"][checkbox value="intranasal capsaicin"][checkbox value="nasal rinse kit"][checkbox value="surgery"]. [text memo="other treatments if any" size="50"]
-Effect of these: [textarea]
-Past Medical History of:
[select value="no|YES"] <-- asthma
[select value="no|YES"] <-- eczema
-Further/other details:
[textarea]
[comment memo="7-point severity scale adapted from Wallace DV, Dykewicz MS, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, Lang DM, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph CC, Schuller D, Spector SL, Tilles SA. The diagnosis and management of rhinitis: An updated practice parameter. Journal of Allergy and Clinical Immunology. 2008;122(2):S1-S84." memo_size="small"]
[comment memo="For use in CRDAMC FM Clinic"]
-Symptoms-
-Worst/most-bothersome symptom-
-Onset- ago
-Frequency of symptoms-
-How bothersome symptoms are to patient? - /7
Severity scale explanation:
1= None- occasional limited episode
3= Mildly bothersome- steady symptoms but easily tolerable
5= Moderately bothersome- symptoms hard to tolerate, may interfere with daily activities and/or sleep
7= Unbearably severe- symptoms are so bad, person can't function all the time

-Symptom Triggers-
<-Pollen from trees, flowers and grasses
<-Mold (both indoors and outdoors)
<-Furred animals (especially cats, dogs and mice)
<-Dust mites
<-Specific seasons
<-Weather/temperature changes (esp. cold temperatures)
<-Tobacco smoke
<-Strong fumes (ie. vehicle exhaust or chemicals)
<-Perfumes
<-Spicy foods (more than just mild runny nose)
<-Other allergens:
-Current treatment(s)-
(ie. claritin/allegra/zyrtec) (ie. flonase/nasonex) (ie. astelin/patanase) (ie. sudaphed or phenyleprhine) (ie. afrin/neosynephrine . other treatments if any
-Prior treatment(s)
(ie. claritin/allegra/zyrtec) (ie. flonase/nasonex) (ie. astelin/patanase) (ie. sudaphed or phenyleprhine) (ie. afrin/neosynephrine . other treatments if any
-Effect of these:
-Past Medical History of:
<-- asthma
<-- eczema
-Further/other details:

7-point severity scale adapted from Wallace DV, Dykewicz MS, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, Lang DM, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph CC, Schuller D, Spector SL, Tilles SA. The diagnosis and management of rhinitis: An updated practice parameter. Journal of Allergy and Clinical Immunology. 2008;122(2):S1-S84.
For use in CRDAMC FM Clinic
Result - Copy and paste this output: