Custom Geriatric Triage

cc: [text size="50"]
HPI:
[text size="30"] is an [text size="3"]-year-old [select value="female|male"] who presents for [select value="initial visit|ongoing visit|acute visit|telephonic visit"]. [select value="Her|His"] PMH is significant for [text size="50"].
-
Interval history:
-Have your medications changed since your last visit? [text size="50"]
-How is your appetite? [text size="50"]
-How is your swallowing? [text size="50"]
-How is your sleeping? [text size="50"]
-How have your bowel and bladder patterns been? [text size="50"]
-How has your walking been, activity? [text size="50"]
-How is your overall mood? [text size="50"]
-Any recent falls? [text size="50"]
-Any recent hospitalizations? [text size="50"]
-
Key history:
-What are you concerned about right now? [text size="50"]
-How much are you able to do around the home? (functional status) [text size="50"]
-What does your home situation and support network look like? [text size="50"]
-When you need support or to talk with a family member, who do you talk to? (family status) [text size="50"]
-Who do you regularly see for medical visits? (PCP and specialists) [text size="50"]
-Where do you pick up your medications? (pharmacy) [text size="50"]
-
Comments:
[comment memo="Additional explanation and context:"][textarea]
cc:
HPI:
is an -year-old who presents for . PMH is significant for .
-
Interval history:
-Have your medications changed since your last visit?
-How is your appetite?
-How is your swallowing?
-How is your sleeping?
-How have your bowel and bladder patterns been?
-How has your walking been, activity?
-How is your overall mood?
-Any recent falls?
-Any recent hospitalizations?
-
Key history:
-What are you concerned about right now?
-How much are you able to do around the home? (functional status)
-What does your home situation and support network look like?
-When you need support or to talk with a family member, who do you talk to? (family status)
-Who do you regularly see for medical visits? (PCP and specialists)
-Where do you pick up your medications? (pharmacy)
-
Comments:
Additional explanation and context:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.13, 24 form elements, 131 boilerplate words, 19 text boxes, 1 text areas, 3 drop downs, 1 comments, 23 total clicks
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