Subjective/History Elements
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[comment memo="Use with Cough symptoms Patient Questionnaire"]
[text size="3"]yo [select name="Sex" value="|M|F"] with cough for [text size="4"] [select value="day(s)|hour(s)|week(s)|month(s)"]
[comment memo="Initial questions"]
-Cough is [select name="prod" value="non-productive|productive"][conditional field="prod" condition="(prod).is('productive')"] - sputum color is [text size="20"][/conditional]
-Cough started when/while [text memo="inciting event" size="80"]
-Remedies/medicines attempted: [text size="80"]
-Effect of attempted remedies/medicines: [text size="80"]
-Since onset, sx have [select value="gotten better|gotten worse|stayed about the same"]
-Patient describes severity is [select value="minimal|moderate|severe"]
-Patient feels cough at nighttime [select value="not significantly affecting sleep|preventing adequate sleep"]
-Patient reports [select value="no known|known"] sick contacts at home, school, or work. [text size="40"]
-Other associated symptoms:
--[select value="no|YES"] <-chest pain with coughing
--[select value="no|YES"] <-coughing up blood
--[select value="no|YES"] <-fever/chills
--[select value="no|YES"] <-body aches
--[select value="no|YES"] <-hoarseness
--[select value="no|YES"] <-sore throat
--[select value="no|YES"] <-runny/stuffy nose
--[select value="no|YES"] <-ear pain
--[select value="no|YES"] <-sinus pain
--[select value="no|YES"] <-itchy/watery eyes
--[select value="no|YES"] <-pain with swallowing
--[select value="no|YES"] <-feeling of lump in throat (globus sensation)
-Hx of these conditions:
--[select value="no|YES"] <-recent cold
--[select value="no|YES"] <-allergic rhinitis
--[select value="no|YES"] <-non-allergic rhinitis
--[select value="no|YES"] <-frequent sinus infection
--[select value="no|YES"] <-asthma
--[select value="no|YES"] <-frequent pneumonia
--[select value="no|YES"] <-frequent bronchitis
--[select value="no|YES"] <-GERD
--[select value="no|YES"] <-head/neck/throat/thyroid/lung cancer
--[select value="no|YES"] <-tuberculosis or positive tuberculin skin test
--[select value="no|YES"] <-Diabetes Mellitus

Tobacco: [checkbox name="tobacco" value="never smoked/chewed/dipped/vaped tobacco/nicotine products|currently smokes/chews/dips/vapes tobacco/nicotine products|formerly smoked/chewed/dipped/vaped tobacco/nicotine products|regularly exposed to second-hand smoke"][conditional field="tobacco" condition="(tobacco).is('currently smokes/chews/dips/vapes tobacco/nicotine products')||(tobacco).is('formerly smoked/chewed/dipped/vaped tobacco/nicotine products')"] [text memo="#packs per day & #years & how long ago quit if applicable" size="20"][/conditional].

Travel: recent travel in past 6 months to foreign country and regular close contact with local people where tuberculosis is endemic- [select value="no|YES"] [text size="50"]

Immunizations: [select value="vaccines UTD per CDC schedule including pertussis|PERTUSSIS VACCINATION STATUS UNKNOWN|UNVACCINATED TO PERTUSSIS"]

[conditional field="Sex" condition="(Sex).is('F')"]
-Currently pregnant- [select name="pg" value="|no|unsure|YES"][/conditional][conditional field="pg" condition="(pg).is('no')||(pg).is('unsure')"]
-Current contraception method: [text size="40"]
-LMP: [text size="10"][/conditional]
[textarea memo="add'l comments"]
[comment memo="For use in CRDAMC FM Clinic"]
Use with Cough symptoms Patient Questionnaire
yo with cough for
Initial questions
-Cough is
-Cough started when/while inciting event
-Remedies/medicines attempted:
-Effect of attempted remedies/medicines:
-Since onset, sx have
-Patient describes severity is
-Patient feels cough at nighttime
-Patient reports sick contacts at home, school, or work.
-Other associated symptoms:
-- <-chest pain with coughing
-- <-coughing up blood
-- <-fever/chills
-- <-body aches
-- <-hoarseness
-- <-sore throat
-- <-runny/stuffy nose
-- <-ear pain
-- <-sinus pain
-- <-itchy/watery eyes
-- <-pain with swallowing
-- <-feeling of lump in throat (globus sensation)
-Hx of these conditions:
-- <-recent cold
-- <-allergic rhinitis
-- <-non-allergic rhinitis
-- <-frequent sinus infection
-- <-asthma
-- <-frequent pneumonia
-- <-frequent bronchitis
-- <-GERD
-- <-head/neck/throat/thyroid/lung cancer
-- <-tuberculosis or positive tuberculin skin test
-- <-Diabetes Mellitus

Tobacco: .

Travel: recent travel in past 6 months to foreign country and regular close contact with local people where tuberculosis is endemic-

Immunizations:


add'l comments
For use in CRDAMC FM Clinic
Result - Copy and paste this output: