Chronic cough

Subjective/History Elements
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[comment memo="*required information"]

[comment memo="Duration"]
has had cough for [text] [checkbox name="duration" value="weeks|months|years"].
[checkbox name="neonatal" value="Symptoms have been present since early infancy.|Patient has no prior respiratory issues."][text name="field_name" default=""]
[comment memo="Cough Description"]
Cough described as [checkbox value="dry/non-productive|wet sounding/productive|usually dry but occasionally productive|usually wet sounding but sometimes dry|hacking"].
[comment memo="Severity"]
Symptom severity reported as [checkbox value="mild|moderate|severe"].
[comment memo="Quality - check NON-SPECIFIC if no description given"]
Cough quality is [checkbox value="non-specific|barky|harsh|loud|honking|hoarse"].
Other details: [comment memo="check NONE if no other details apply"][checkbox value="None|Clear sputum|Purulent sputum|Post-tussive emesis"].
[comment memo="Frequency"]
Symptoms are present [checkbox name="field_name" value="infrequently|intermittently|constantly"][text name="field_name" default=""].
[comment memo="Progression"][checkbox value="Symptoms becoming more frequent and/or worsening.|Frequency and severity of symptoms are stable/unchanged."] [text name="field_name" default=""]
[comment memo="Foreign Body Aspiration History"]
[checkbox value="No known choking or gagging episode.|Cough onset after a choking and gagging episode."][text name="field_name" default="No significant suspicion for foreign body aspiration."]
[comment memo="Nocturnal sx"]
[checkbox value="Patient does not cough during sleep.|Patient coughs at night."][comment memo="If patient coughs at night, please specify below how it affects sleep"]
Symptoms [checkbox value="never|sometimes|often|always"] interfere with sleep.
[comment memo="Include ALL other pertinent information below"][textarea name="field_name" default=""]

Timing and Triggers
Cough has been associated with [comment memo="POSITIVE cough pointers -check ALL that apply"][checkbox value="feeding|colds/viral illnesses|allergy symptoms|reflux symptoms|exercise/exertion|NO particular activity (i.e., occurs randomly)"]. [text name="field_name" default=""]
Symptoms NOT associated with [comment memo="NEGATIVE cough pointers -check ALL that apply"][checkbox value="feeding|colds/viral illnesses|allergy symptoms|reflux symptoms|exercise/exertion"].

Other reported symptoms:[comment memo="check all that apply"][checkbox value="None|wheezing|wheezing with exertion/exercise|chest congestion|shortness of breath|chest tightness|nasal congestion|postnasal drip|watery, itchy eyes|sneezing|throat clearing|heartburn|hemoptysis|fever|fatigue|weight loss|night sweats"].
[comment memo="Pattern"]
Seasonality: [checkbox name="occurence" value="All year|Spring|Summer|Fall|Winter|with weather changes|Random|No seasonal predilection"].

[comment memo="Please check below ONLY if habit cough suspected (usually pts > 5 years old."]
[checkbox value="Cough worsens when child is anxious or attention is focused.|Cough improves with distraction or suggestion, and can be voluntarily suppressed."]
Exposures:[comment memo="check ALL that apply"]
[checkbox value="No history of recent travel or immigration."] [checkbox value="No known sick contacts."] [checkbox value="No known exposure to animals."] [checkbox value="No new exposures at home and/or in school."] [checkbox value="No known contact with Tuberculosis."] [checkbox value="No known contact with Pertussis."]
[checkbox value="Known or Suspected exposure to"] [text name="field_name" default=""][comment memo="Describe detail/s of exposure/s"]

Comorbidities: [checkbox value="none|seasonal and/or environmental allergies|gastroesophageal reflux (GERD)|dysphagia|neuromuscular disease"][text].[comment memo="others - specify"]

History of Pulmonary Problems: [checkbox value="None/No prior respiratory problems|recurrent pneumonia|frequent bronchitis|asthma|other"][comment memo="Describe problems"][text name="field_name" default=""]

Medications previously administered or prescribed for current symptoms: [checkbox name="meds" value="None|Anti-reflux meds|Albuterol|Tessalon Perles|Codeine|Systemic steroids (short burst)|Singulair|Inhaled cortecosteroids"]
[comment memo="specify: ICS + dose, other meds)"][textarea name="field_name" default=""]

Allergy Medications: [checkbox value="None|Cetirizine (Zyrtec)|Fexofenadine (Allegra)|Levocetirizine (Xyzal)|Loratadine (Claritin, Alavert)|Triamcinolone (Nasacort AQ)|Fluticasone (Flonase, Veramyst)|Azelastine + Fluticasone (Dymista)|Beclomethasone (QNASL, Beconase AQ)|Mometasone (Nasonex)"][text] [comment memo="Others - specify"]

Over the counter medications that have been tried:[comment memo="check all that apply, otherwise check NONE"][checkbox value="None"][checkbox value="Dextromethorphan|Guaifenesin"]
[comment memo="DM brands: Triaminic Cold and Cough, Robitussin Cough, Vicks 44 Cough and Cold;
GUAIFENESIN brands: Mucinex, Robitussin Chest Congestion. Others - SPECIFY"] [textarea name="field_name" default=""]

Tobacco Smoke Exposure:[comment memo="include details of exposure - e.g., who smokes, location of exposure, etc"] [checkbox value="No exposure to 2nd or 3rd hand smoke.|Patient is exposed to second hand smoke."] [text name="field_name" default=""]
[checkbox value="Patient is not a smoker.|Patient is a current or former smoker."]
*required information

Duration
has had cough for .

Cough Description
Cough described as .
Severity
Symptom severity reported as .
Quality - check NON-SPECIFIC if no description given
Cough quality is .
Other details: check NONE if no other details apply .
Frequency
Symptoms are present .
Progression
Foreign Body Aspiration History

Nocturnal sx
If patient coughs at night, please specify below how it affects sleep
Symptoms interfere with sleep.
Include ALL other pertinent information below

Timing and Triggers
Cough has been associated with POSITIVE cough pointers -check ALL that apply .
Symptoms NOT associated with NEGATIVE cough pointers -check ALL that apply .

Other reported symptoms:check all that apply .
Pattern
Seasonality: .

Please check below ONLY if habit cough suspected (usually pts > 5 years old.

Exposures:check ALL that apply

Describe detail/s of exposure/s

Comorbidities: .others - specify

History of Pulmonary Problems: Describe problems

Medications previously administered or prescribed for current symptoms:
specify: ICS + dose, other meds)

Allergy Medications: Others - specify

Over the counter medications that have been tried:check all that apply, otherwise check NONE
DM brands: Triaminic Cold and Cough, Robitussin Cough, Vicks 44 Cough and Cold;
GUAIFENESIN brands: Mucinex, Robitussin Chest Congestion. Others - SPECIFY


Tobacco Smoke Exposure:include details of exposure - e.g., who smokes, location of exposure, etc
Result - Copy and paste this output:

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