Dizziness History

[checkbox memo="Short Version" name="short" value=""][conditional field="short" condition="(short).is('')"][textarea default="Source of history: son|daughter|spouse|father|mother.  Patient has had dizziness for ***.  Other symptoms include lightheadedness|vertigo|sensation of motion|tinnitus|decreased hearing|nausea|vomiting|weakness.  Onset abruptly|insidiously.  Symptoms have waxed and waned|increased|decreased|been stable.  Associated symptoms include headache|palpitations|chest pain|anxiety.  Symptoms are affecting ability to work|activities of daily living.  Aggravating factors include movement|loud noises|activity|food|change in posture.  Alleviating factors include laying down|avoiding movement|OTC motion sickness treatment.  Patient has past history of similar symptoms|Meniere's disease|syncope|orthostasis|cerebrovascular disease|diabetes|CAD|cardiac arrhythmia.  "][/conditional][checkbox memo="Long Version" name="long" value=""][conditional field="long" condition="(long).is('')"]Dizziness
The episode happened [text] before this evaluation
Onset while [text].
Episode location: [text]
Episode description: [text]
The last similar episode was [text]
Key symptoms
[select value="no|YES"] <-- vertigo  [text]
[select value="no|YES"] <-- hearing loss [text]
[select value="no|YES"] <-- tinnitus [text]
[select value="no|YES"] <-- lightheadedness [text]
[select value="no|YES"] <-- ataxia or impaired balance [text]
[select value="no|YES"] <-- near-syncope [text]
[select value="no|YES"] <-- complete loss of consciousness [text]
[select value="no|YES"] <-- seizure activity [text]
[select value="no|YES"] <-- confusion [text]
[select value="no|YES"] <-- generalized weakness [text]
[select value="no|YES"] <-- palpitations [text]
Associated symptoms:
[select value="no|YES"] <-- chest pain [text]
[select value="no|YES"] <-- dyspnea [text]
[select value="no|YES"] <-- nausea or vomiting [text]
[select value="no|YES"] <-- headache [text]
[select value="no|YES"] <-- visual changes [text]
[select value="no|YES"] <-- abdominal pain [text]
[select value="no|YES"] <-- bleeding (e.g. stool, urine, vagina) [text]
[select value="no|YES"] <-- low blood sugar [text]
Past Medical History
[select value="no|YES"] <-- Recent upper respiratory infection [text]
[select value="no|YES"] <-- Recent trauma [text]
[select value="no|YES"] <-- Seizure history [text]
[select value="no|YES"] <-- Diabetes mellitus history [text]
[select value="no|YES"] <-- Coronary artery disease history [text]
[select value="no|YES"] <-- Cerebrovascular accident history [text]
[select value="no|YES"] <-- Gastrointestinal bleeding history [text]
[select value="no|YES"] <-- Other (e.g. pregnancy in women of child bearing age) [text]
Cardiovascular risks reviewed
[select value="no|YES"] <-- Family history of Premature CAD or CVA (<55) [text]
[select value="no|YES"] <-- Tobacco use [text]
[select value="no|YES"] <-- Hyperlipidemia [text]
[select value="no|YES"] <-- Hypertension[/conditional]
[checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"]
reference: Long Version contributed by Dr. Scott Moses, creator/author of the Family Practice Notebook [link url="http://www.fpnotebook.com" memo="website"][/conditional]
Short Version Long Version
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