[comment memo="*" memo_color="blue" memo_size="small"]cc/reason for visit: [text size="60"]
[comment memo="*" memo_color="blue" memo_size="small"]HPI: [text size="5"] yo [select name="Gender" value="M|F"] here for-
[comment memo="Acute conditions" memo_size="small" memo_color="blue"]
[checkbox name="generalsxHPI1" memo="generic #1" memo_size="small" value="Symptoms"][conditional field="generalsxHPI1" condition="(generalsxHPI1).is('Symptoms')"]
-Symptoms: [text size="50"].
-Symptoms started [text size="3"] [select value="hour(s)|day(s)|week(s)|month(s)|year(s)"] ago.
-Patient reports these symptoms are located [text size="35"].
-Patient reports these symptoms are [select value="getting worse|getting better|the same"] since onset.
-Rates it as [text size="5"]/10 in severity.
-Describes the character/quality as [checkbox value="sharp|dull|burning|tingling|N/A"][text size="30"].[comment memo="Other comments on character/quality" memo_size="small"]
-Above symptom(s) [select value="do not travel/radiate|travel/radiate to"] [text size="25"].
-Associated sx: [checkbox value="Denies any associated symptoms"][text size="25"].
-Related activities or events that occured at or right before symptoms started: [text size="80"].
-Therapies attempted: [text size="80"].
-Symptoms are improved with [text size ="50"].
-Symptoms are worsened by [text size="50"].
-Patient [select value="denies|admits to"] history of similar symptoms previously.
-Additional comments- [textarea default="none"]
[/conditional][checkbox name="generalsxHPI2" memo="generic #2" memo_size="small" value="Symptoms"][conditional field="generalsxHPI2" condition="(generalsxHPI2).is('Symptoms')"]
-Symptoms: [text size="50"].
-Symptoms started [text size="3"] [select value="hour(s)|day(s)|week(s)|month(s)|year(s)"] ago.
-Patient reports these symptoms are located [text size="35"].
-Patient reports these symptoms are [select value="getting worse|getting better|the same"] since onset.
-Rates it as [text size="5"]/10 in severity.
-Describes the character/quality as [checkbox value="sharp|dull|burning|tingling|N/A"][text size="30"].[comment memo="Other comments on character/quality" memo_size="small"]
-Above symptom(s) [select value="do not travel/radiate|travel/radiate to"] [text size="25"].
-Associated sx: [checkbox value="Denies any associated symptoms"][text size="25"].
-Related activities or events that occured at or right before symptoms started: [text size="80"].
-Therapies attempted: [text size="80"].
-Symptoms are improved with [text size ="50"].
-Symptoms are worsened by [text size="50"].
-Patient [select value="denies|admits to"] history of similar symptoms previously.
-Additional comments- [textarea default="none"]
[/conditional][checkbox memo="URI" memo_size="small" name="HPIforURI" value="Upper Respiratory Sx"][conditional field="HPIforURI" condition="(HPIforURI).is('Upper Respiratory Sx')"]
-Symptoms: [checkbox name="URTIsx" value="runny nose|stuffy nose|itchy eyes|watery eyes|ear pain|sinus pain in cheeks and/or forehead|sore throat|pain with swallowing|difficulty swallowing|hoarseness|productive cough|dry cough|fever|chills|body aches"]
-Duration: [text size="4"] [select value="day(s)|week(s)"]
[/conditional][conditional field="URTIsx" condition="(URTIsx).is('ear pain')||(URTIsx).is('sinus pain in cheeks and/or forehead')||(URTIsx).is('sore throat')||(URTIsx).is('pain with swallowing')"]-Pain severity: [text size="4"]/10
[/conditional][conditional field="HPIforURI" condition="(HPIforURI).is('Upper Respiratory Sx')"]-Is sore throat the main complaint without concurrent cold-like symptoms (nose/eyes/etc)? [select name="Centor" value="no|YES"][comment memo="Choose 'yes' to bring up Centor Criteria" memo_size="small"][/conditional][conditional field="Centor" condition="(Centor).is('YES')"]
Modified Centor Score
[select name="Q1Fever" value="No (0 points)=0|YES (1 point)=1"] <-- History of fever or measured temperature > 100.4 degrees F
[select name="Q2Cough" value="Cough is present (0 points)=0|COUGH IS ABSENT (1 point)=1"] <-- Presence of coughing
[select name="Q3Nodes" value="No (0 points)=0|YES (1 point)=1"] <-- Tender anterior cervical nodes
[select name="Q4Tonsil" value="No (0 points)=0|YES (1 point)=1"] <-- Tonsillar swelling or exudates
[select name="Q5Age" value="< 15 years (1 point)=1|15 to 45 years (0 points)=0|> 45 years (-1 point)=-1"] <-- Age
Score --> [calc value="score=(Q1Fever)+(Q2Cough)+(Q3Nodes)+(Q4Tonsil)+(Q5Age)" memo="score"][/conditional][conditional field="HPIforURI" condition="(HPIforURI).is('Upper Respiratory Sx')"]
[comment memo="modifying factors" memo_size="small"]
-Therapies tried that have improved symptoms: [text size="50"]
-Therapies tried that have NOT improved symptoms: [text size="50"]
-Additional comments- [textarea default="none"]
-Review of Systems: [checklist value="Fever|Chills|Body aches|Chest pain|Nausea|Vomiting|Diarrhea"]
[/conditional][checkbox memo="cough/chest symptoms" memo_size="small" name="HPIforCough" value="Respiratory Sx"][conditional field="HPIforCough" condition="(HPIforCough).is('Respiratory Sx')"]
-Symptoms- [checkbox value="cough|mild chest pain|chest tightness|shortness of breath|other-"] [text size="60"]
-Duration: [text size="4"] [select value="day(s)|hour(s)|week(s)|month(s)"]
-[select name="coughprod" value="Denies cough|Non-productive cough|Productive cough"][/conditional][conditional field="coughprod" condition="(coughprod).is('Productive cough')"] - sputum color is [text size="20"][/conditional][conditional field="HPIforCough" condition="(HPIforCough).is('Respiratory Sx')"]
-Symptoms started when/while [text memo="inciting event" memo_size="small" 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"]
-Additional comments- [textarea default="none"]
-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
-[select value="no|YES"] <-Previous use of tobacco products or vaping {textarea memo="if tobacco hx include heaviest daily/weekly use and #years" memo_size="small"]
-Review of systems:
-[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)
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"]
Immunization status: [checkbox value="vaccines UTD (incl pertussis/PCV if indicated)|PERTUSSIS VACCINATION STATUS UNKNOWN|UNVACCINATED TO PERTUSSIS|PNEUMOCOCCAL VACCINE INDICATED BY NOT RECEIVED"]
[/conditional][checkbox memo="N/V/D/pain" memo_size="small" name="HPIforGI" value="Gastrointestinal Sx"][conditional field="HPIforGI" condition="(HPIforGI).is('Gastrointestinal Sx')"]
-Symptoms- [checkbox name="GIsx" value="decreased appetite|bloating sensation|pain with defecation|constipation|diarrhea|abdominal pain|nausea/vomiting|other-"] [text size="60"]
-Sx started [text size="4"] [select value="day(s)|hour(s)|week(s)|month(s)"] ago
-Sx started when/while [text size="80"]
-Last BM was [text size="4"] [select value="day(s)|hour(s)|week(s)"] ago and consistency was [select value="soft|slightly firm|very hard|loose|like water"], and color was described as [text size="40"].
-#BMs in past 24hrs: [text size="4"]
-Last meal eaten was [text size="4"] [select value="hour(s)|day(s)"] ago
-Therapies/medications attempted- [text size="80"]
-Sx improved by [text size="50"]
-Sx worsened by [text size="50"]
-Since onset, sx have [select value="gotten better|gotten worse|stayed about the same"][/conditional][conditional field="GIsx" condition="(GIsx).is('abdominal pain')"]
-Pain Location: [text size="50"]
-Pain Radiation: [text size="50"]
-Pain Severity currently: [text size="5"]/10
-Pain Severity at worst: [text size="5"]/10
-Pain Timing: [select value="constant|comes and goes"] Duration of pain if episodic: [text default="n/a" size="50"]
-Pain described as: [select value="both sharp and dull|sharp/knifelike|dull/pressure|other-"] [text size="50"]
[/conditional][conditional field="GIsx" condition="(GIsx).is('nausea/vomiting')"][comment memo="N/V specific questions"]
-[select value="no|YES"] <-- nausea
-[select value="no|YES"] <-- vomiting [text][comment memo="if yes, indicate color" memo_size="small"]
[comment memo="Exposures"]
-[select value="no|YES"] <-- Recent intake of questionable/new food
-[select value="no|YES"] <-- Recent antibiotics
-[select value="no|YES"] <-- Recent travel
[/conditional][conditional field="HPIforGI" condition="(HPIforGI).is('Gastrointestinal Sx')"]-Additional comments- [textarea default="none"]
-Review of Systems:
-[select value="no|YES"] <-- Chest pain or chest/belly pain with breathing
-[select value="no|YES"] <-- Black or bloody stool
-[select value="no|YES"] <-- Fever
-[select value="no|YES"] <-- Dysuria
-[select value="no|YES"] <-- Urinary frequency
-[select value="no|YES"] <-- Urinary urgency
-[select value="no|YES"] <-- Hematuria
-Hx of these conditions:
-[select value="no|YES"] <-- Gall Bladder or liver disease
-[select value="no|YES"] <-- GERD
-[select value="no|YES"] <-- Peptic ulcer(s)
-[select value="no|YES"] <-- Pancreatitis
-[select value="no|YES"] <-- Kidney stones
-[select value="no|YES"] <-- Urinary tract infections
-[select value="no|YES"] <-- Diverticulitis
-[select value="no|YES"] <-- Inflammatory Bowel Disease
-[select value="no|YES"] <-- Pelvic Infection
-[select value="no|YES"] <-- Vascular disease
-Hx of these surgeries:
-[select value="no|YES"] <-- Appendectomy
-[select value="no|YES"] <-- Cholecystectomy
-Currently using: [comment memo="pertinent meds/substances"]
-[select value="no|YES"] <-- Daily or near-daily use of NSAIDs
-[select value="no|YES"] <-- Daily or near-daily alcohol use
-[select value="no|YES"] <-- Daily or near-daily use of Opioids
-[select value="no|YES"] <-- aortic aneurysm history or risk (age over 60, tobacco history)
[/conditional][checkbox memo="#1" memo_size="small" name="HPIforMSK1" value="MSK Sx"][conditional field="HPIforMSK1" condition="(HPIforMSK1).is('MSK Sx')"]
-Symptoms: [checkbox value="pain|popping|grinding|joint weakness|other-"] [text size="60"]
-Onset: [text size="3"] [select value="days|weeks|months|years"]
-Location: [text size="40"]
-Pain started while/after: [checkbox value="no specific inciting event"][text size="80"]
-Pain Radiation: [checkbox value="none"][text size="50"]
-Timing: [select name="MSK1Timing" value="constant|comes and goes"][/conditional][conditional field="MSK1Timing" condition="(MSK1Timing).is('comes and goes')"] -->
Portion(s) of day when it occurs mostly: [text size="40"][/conditional][conditional field="HPIforMSK1" condition="(HPIforMSK1).is('MSK Sx')"]
-Type/quality of pain: [select value="|sharp/knifelike|dull/pressure|both sharp and dull"] [text size="40"]
-Action/activity that bothers most: [text size="50"]
-Other aggravating actions/activities: [text size="80"]
-Progression of pain: [select value="getting better|getting worse|staying the same"]
-Severity of pain: [text size="5"]/10
-Previously seen for this: [select name="MSK1PrevVisit" value="|no|YES"][/conditional][conditional field="MSK1PrevVisit" condition="(MSK1PrevVisit).is('YES')"]
-Number of visits: [text size="4"].
-Specialties seen: [checkbox value="primary care|physical therapy|orthopedist|chiropractor|acupuncturist|pain management specialist"] [text size="30"][/conditional][conditional field="HPIforMSK1" condition="(HPIforMSK1).is('MSK Sx')"]
-Modalities attempted: [checkbox value="none|home remedies|stretches|rest|ice|heat|elevation|medications|physical therapy|injections|surgery|other-"] [text size="60"]
-Effect of these modalities: [select value="helped pain|worsened pain|made no difference|mixed -see additional comments"]
-Other associated symptoms:
-[select value="n/a|no|YES"] <-if knee involved, any locking up of joint when attempting movement
-[select value="n/a|no|YES"] <-if knee involved, any buckling or giving-out of joint with use
-[select value="n/a|no|YES"] <-if joint involved, any swelling
-[select value="n/a|no|YES"] <-if joint involved, any stiffness
-[select value="no|YES"] <-any fevers or chills
-[select value="no|YES"] <-any recent tick exposure within the past year
-Additional comments- [textarea default="none"]
[/conditional][checkbox memo="#2" memo_size="small" name="HPIforMSK2" value="MSK Sx"][conditional field="HPIforMSK2" condition="(HPIforMSK2).is('MSK Sx')"]
-Symptoms: [checkbox value="pain|popping|grinding|joint weakness|other-"] [text size="60"]
-Onset: [text size="3"] [select value="days|weeks|months|years"]
-Location: [text size="40"]
-Pain started while/after: [checkbox value="no specific inciting event"][text size="80"]
-Pain Radiation: [checkbox value="none"][text size="50"]
[select name="MSK2Timing" value="constant|comes and goes"][/conditional][conditional field="MSK2Timing" condition="(MSK2Timing).is('comes and goes')"] -->
Portion(s) of day when it occurs mostly: [text size="40"][/conditional][conditional field="HPIforMSK2" condition="(HPIforMSK2).is('MSK Sx')"]
-Type/quality of pain: [select value="|sharp/knifelike|dull/pressure|both sharp and dull"] [text size="40"]
-Action/activity that bothers most: [text size="50"]
-Other aggravating actions/activities: [text size="80"]
-Progression of pain: [select value="getting better|getting worse|staying the same"]
-Severity of pain: [text size="5"]/10
-Previously seen for this: [select name="MSK2PrevVisit" value="|no|YES"][/conditional][conditional field="MSK2PrevVisit" condition="(MSK2PrevVisit).is('YES')"]
-Number of visits: [text size="4"].
-Specialties seen: [checkbox value="primary care|physical therapy|orthopedist|chiropractor|acupuncturist|pain management specialist"] [text size="30"][/conditional][conditional field="HPIforMSK2" condition="(HPIforMSK2).is('')"]
-Modalities attempted: [checkbox value="none|home remedies|stretches|rest|ice|heat|elevation|medications|physical therapy|injections|surgery|other-"] [text size="60"]
-Effect of these modalities: [select value="helped pain|worsened pain|made no difference|mixed -see additional comments"]
-Other associated symptoms:
-[select value="n/a|no|YES"] <-if knee involved, any locking up of joint when attempting movement
-[select value="n/a|no|YES"] <-if knee involved, any buckling or giving-out of joint with use
-[select value="n/a|no|YES"] <-if joint involved, any swelling
-[select value="n/a|no|YES"] <-if joint involved, any stiffness
-[select value="no|YES"] <-any fevers or chills
-[select value="no|YES"] <-any recent tick exposure within the past year
-Additional comments- [textarea default="none"]
[/conditional][checkbox memo="urinary/penile/STD concerns" memo_size="small" name="HPIforMaleGU" value="Male GU Sx"][conditional field="HPIforMaleGU" condition="(HPIforMaleGU).is('Male GU Sx')"]
-Symptoms: [text memo="other/not listed" memo_size="small" size="60"][checkbox name="maleGUsxdischarge" value="penile discharge"][/conditional][conditional field="maleGUsxdischarge" condition="(maleGUsxdischarge).is('penile discharge')"](color/consistency - [text size="60"]), [/conditional][conditional field="HPIforMaleGU" condition="(HPIforMaleGU).is('Male GU Sx')"][checkbox value="penis tenderness|scrotal pain|penis rash/lesion|pain with urinating|urinary frequency|urinary urgency|blood in urine|blood in semen"][checkbox name="maleGUsxdifficulturine" value="difficulty urinating"][/conditional][conditional field="maleGUsxdifficulturine" condition="(maleGUsxdifficulturine).is('difficulty urinating')"] (last urinated [text size="5"][select value="minute(s)|hour(s)|day(s)"] ago, amount was [select value="a drop|scant/small|average amt|large amt"])[/conditional][conditional field="HPIforMaleGU" condition="(HPIforMaleGU).is('Male GU Sx')"]
-Onset- [text size="3"] [select value="hour(s)|day(s)|week(s)|month(s)|year(s)"] ago.
-Symptoms first noticed during/after- [checkbox value="no reported inciting event"][text size="80"]
-Symptoms are located- [checkbox value="n/a"][text size="60"]
-Symptoms character/quality: [checkbox value="N/A|both sharp and dull|sharp/knifelike|dull/pressure|burning|tingling|other-"] [text size="80"]
-Symptom radiation- [checkbox value="none|travel/radiate to"][text size="80"]
-Symptom timing- [select name="maleGUsxtiming" value= "constant|intermittent/comes and goes"][/conditional][conditional field="maleGUsxtiming" condition="(maleGUsxtiming).is('intermittent/comes and goes')"]
-Sx episodes last [text size="5"][select value="second(s)|minute(s)|hour(s)|day(s)|week(s)|month(s)"][/conditional][conditional field="HPIforMaleGU" condition="(HPIforMaleGU).is('Male GU Sx')"]
-Sx progression: [select value="the same|getting worse|getting better"] since onset
[checkbox name="maleGUsxpainscale" memo="pain scale if applicable" memo_size="small" value=""][/conditional][conditional field="maleGUsxpainscale" condition="(maleGUsxpainscale).is('')"]-Pain rated as [text size="4"]/10 in severity currently, at its worst [text size="4"]/10
[/conditional][conditional field="HPIforMaleGU" condition="(HPIforMaleGU).is('Male GU Sx')"]
-Symptoms are worsened by- [checkbox value="nothing"][text size="80"]
-Therapies attempted- [checkbox value="none"][text size ="80"]
-Effect of these therapies: [select value="helped|worsened|made no difference|mixed -see additional comments"]
-Patient [select value="denies|admits to"] history of similar symptoms previously
-Sexually active? [select name="maleGUsxSex" value="no|Yes"][/conditional][conditional field="maleGUsxSex" condition="(maleGUsxSex).is('Yes')"]
-Number of sexual partners in past year *[text size="3"]*[/conditional][conditional field="HPIforMaleGU" condition="(HPIforMaleGU).is('Male GU Sx')"]
-Additional comments- [textarea default="none"]
Associated Sx/Review of Systems:
[checklist value="fever/chills|decreased appetite|nausea|vomiting|diarrhea|constipation|black or bloody stool"]
Pertinent History
[checklist name="maleGUrosSTD" value="STD"][/conditional][conditional field="maleGUrosSTD" condition="(maleGUrosSTD).is('YES')"] - [comment memo="include which type, how long ago, and how many prior episodes" memo_size="small" memo_color="orange"][textarea rows="2"][/conditional][conditional field="HPIforMaleGU" condition="(HPIforMaleGU).is('Male GU Sx')"]
[checklist value="Epididymitis|Prostatitis|BPH|Prostate Cancer|Kidney stones|Urinary tract infections|Diverticulitis"]
Pertinent Past Surgeries:
[checklist value="Appendectomy|Prostatectomy"]
[/conditional][checkbox memo="itching/pain/discharge/STD concerns" memo_size="small" name="HPIforFemaleGU" value="Female GU Sx"][conditional field="HPIforFemaleGU" condition="(HPIforFemaleGU).is('Female GU Sx')"]
-G[text memo="#pregnancies" memo_size="small" size="2"] P[text memo="#deliveries" memo_size="small" size="2"]
-Symptoms: [text memo="other/not listed" memo_size="small" size="60"][checkbox name="FemaleGUsx" value="unusual vaginal bleeding|unusual vaginal discharge|vaginal itching/irritation|vaginal pain"]
-Onset- [text size="3"] [select value="hour(s)|day(s)|week(s)|month(s)|year(s)"] ago.
-Symptoms first noticed during/after: [checkbox value="no reported inciting event"][text size="80"]
-Symptoms are located: [checkbox value="n/a"][text size="60"]
-Symptom progression: [select value="gotten better|gotten worse|stayed about the same"]
-Bowel movements/stools consistency usually [select value="soft|slightly firm|very hard|loose|like water"], and frequency is [text size="3"] stool(s) every [text size="3"] days.
-Therapies attempted: [checkbox value="none"][text size ="80"]
-Effect of these therapies: [select value="helped|worsened|made no difference|mixed -see explanation"]
[/conditional][conditional field="FemaleGUsx" condition="(FemaleGUsx).is('unusual vaginal discharge')||(FemaleGUsx).is('vaginal itching/irritation')"]
-Color/consistency of vaginal discharge (if present): [checkbox value="n/a|white|cottage cheese like|yellow/green vaginal discharge|frothy|malodorous|bloody"]
-Uses cleansing products inside the vagina (other than water)- [select value="no|YES"] [text size="60"][/conditional][conditional field="FemaleGUsx" condition="(FemaleGUsx).is('vaginal pain')"]
-Symptom radiation- [checkbox value="none|travel/radiate to"][text size="80"]
-Severity currently: [text size="5"]/10
-Severity at worst: [text size="5"]/10
-Timing: [select value="constant|comes and goes"]
-Duration of pain if episodic: [text default="n/a" size="50"]
-Described as: [select value="both sharp and dull|sharp/knifelike|dull/pressure|burning|other-"] [text size="50"]
-Worse with intercourse: [select value="no|YES"][/conditional][conditional field="HPIforFemaleGU" condition="(HPIforFemaleGU).is('Female GU Sx')"]
-Sexually active: [select value="|Yes|no"]
-Additional comments- [textarea default="none"]
-Review of Systems: [checklist value="dysuria|urinary frequency|hematuria|decreased appetite|nausea|vomiting|back/flank pain|pelvic pain|black or bloody stool|fever"]
-Hx of these conditions:
[checklist value="STD/STI|Ectopic Pregnancy|Endometriosis|Ovarian Cyst|Kidney Stones|Urinary Tract Infections|Diverticulitis|Diabetes Mellitus|Candida Vaginitis recent/recurrent|Bacterial Vaginosis recent/recurrent|Trichomonas vaginitis|Atrophic Vaginitis|PID|recent new sexual partner|multiple sexual partners in the past year"]
-Past Surgeries:
[checklist value="Appendectomy|Ceserean Section|Hysterectomy|Tubal ligation|Other abdominal/pelvic surgeries"] [textarea memo="explanation of other abd/pelv surgeries" memo_size="small" rows="2"]
[/conditional][checkbox memo="UTI sx" memo_size="small" name="HPIforUTI" value="Urinary Sx"][conditional field="HPIforUTI" condition="(HPIforUTI).is('Urinary Sx')"]
-Symptoms: [text memo="other/not listed" memo_size="small" size="60"][checkbox value="dysuria|frequency|urgency|incontinence|hematuria|cloudy urine|fever|chills|vaginal discharge|flank pain"]
-Onset- [text size="3"] [select value="hour(s)|day(s)|week(s)|month(s)|year(s)"] ago.
-Symptoms first noticed during/after- [checkbox value="no reported inciting event"][text size="80"]
-Symptoms are worsened by- [checkbox value="nothing"][text size="80"]
-Therapies attempted: [checkbox value="none"][text size ="80"]
-Effect of these therapies: [select value="helped|worsened|made no difference|mixed- see comments"]
-Symptom progression: [select value="gotten better|gotten worse|stayed about the same"]
-Previous episodes: [select value="denies|admits"] to a UTI in the past. [text size="60"]
-Additional comments- [textarea default="none"]
Review of systems: [checklist value="symptoms >7 days duration|shaking chills|flank pain|temp >101F|nausea|vomiting|abdominal pain|change in vaginal/penile discharge or odor|painful with intercourse"]
Pertinent medical history: [checklist value="pyelonephritis within the last 3 months|diabetes|current/recent pregnancy|immunosuppression|kidney stones|kidney failure|catheterization within the last 2 weeks|hospitalization or nursing home residency within the last 2 weeks|4 or more UTIs within the last 12 months|antibiotic for a UTI in the last 4 weeks
[/conditional][checkbox memo="headaches/migraines" memo_size="small" name="HPIforHeadache" value="Headache Sx"][conditional field="HPIforHeadache" condition="(HPIforHeadache).is('Headache Sx')"]
-Symptoms: [text memo="other/not listed" memo_size="small"][checkbox value="headache"]
-Onset- [text size="3"] [select value="hour(s)|day(s)|week(s)|month(s)|year(s)"] ago.
-Symptoms first noticed during/after: [checkbox value="no reported inciting event"][text size="80"]
-Symptom location- [text size="60"]
-Symptom radiation- [checkbox value="none"][text size="80"]
-Pain severity- currently [text size="5"]/10; at worst [text size="5"]/10
-Characterized as- [text size="60"][checkbox value="sharp|dull|throbbing|pounding"]
-Symptom progression: [select value="getting better|GETTING WORSE|the same"]
-Therapies/medications tried- [checkbox value="none"][text size="80"]
-Pain improved with [checkbox value="nothing"][text size="30"].
-Pain worsened by [checkbox value="nothing"][text size="30"].
-#Episodes per [select value="month|week"]- [checkbox value="n/a"][text size="5"]
-Additional comments- [textarea default="none"]
Review of Symptoms: [checklist value="worse with bright lights|worse with loud noises|nausea/vomiting|preceding aura before the headache (e.g. vision change, smell, other symptom prodrome)|blurred vision|fever|sinus pressure or nasal drainage|arm/leg weakness"]
[textarea memo="explanation of positives" memo_size="small" cols="2"]
Pertinent PMH: [checklist value="Migraine Headache|Frequent Sinusitis|Glaucoma|Head Trauma|Serious CNS risks (e.g. active cancer, immunosuppression, HIV)|Exposures (e.g. Tick bites, carbon monoxide)|Family history of cerebral aneurysm or stroke"]
[/conditional][checkbox memo="insomnias/parasomnias" memo_size="small" name="HPIforSleep" value="Sleep Concerns"][conditional field="HPIforSleep" condition="(HPIforSleep).is('Sleep Concerns')"]
-Symptoms: [text memo="other/not listed" memo_size="small" size="80"][checkbox value="difficulty getting to sleep|difficulty staying asleep|legs/arms restless feeling|not feeling rested when waking up for the day|excessive sleepiness during the day"]
-Duration: [text size="5"] [select value="day(s)|week(s)|month(s)|year(s)"]
-Specific life event that during/afterwards the symptoms started: [checkbox value="none/denies"][textarea rows="2"]
-Symptom progression: [select value="gotten better|gotten worse|no change"]
-Therapies attempted: [textarea memo="other/not listed" memo_size="small" rows="2"]
[comment memo="Sleep hygiene, stimulus and temporal control" memo_size="small"][checklist value="Lie down to sleep only when feeling sleepy|Avoid wakeful activities at bedtime (watching television, talking on the phone, eating)|Leave the bed if unable to fall asleep within 20 minutes and return when sleepy|Maintaining consistent bed/wake times (including weekends/days-off)|Avoiding daytime naps|Exercise regularly (not within 4 hours of bedtime, outside of unit PT)|Avoiding large meals and limit fluid intake in the evenings|Limiting caffeine, tobacco, and alcohol use|Using the bedroom for only sleep/sex|Avoiding distracting stimuli at bedtime like loud noises, bright lights when not being used therapeutically, and extreme temperature variations|Ear-plugs used to limit noise"][comment memo="Sleep restriction" memo_size="small"][checklist value="Limiting time in bed to the number of hours actually spent sleeping (not less than 5 hours, sleep time gradually increases as sleep efficiency improves)"][comment memo="Paradoxical intention" memo_size="small"][checklist value="Focuses on remaining awake in calm environment to address the anxiety a/w the pressure to fall asleep"][comment memo="Relaxation training" memo_size="small"][checklist value="Autogenic training (imagining a calm environment with comforting body perceptions such as warmth and heaviness of the limbs)|Imagery training (focus on pleasant images)|Repetitive focus (focus on a word, sound, prayer, phrase, or muscle activity)|Hypnosis|Meditation|Yoga|Abdominal breathing|Progressive muscle relaxation (from the feet up to the facial muscles)|Paced respirations (Take a deep breath and hold for five seconds, repeat several times; focus on the sound of the breath)"]
-Effect of attempted therapies: [select value="helped|worsened|no difference|mixed- see comments"]
-Additional comments- [textarea default="none"]
-Pertinent PMHx review:
[checklist value="Generalized Anxiety D/O|Major Depressive D/O|Adjustment D/O|Bipolar D/O|PTSD|TBI|ADHD|Sleep paralysis|Restless Legs Syndrome|Sleep Apnea|GERD|Asthma/COPD/CHF|MSK chronic issues that cause pain at night"]
-Review of systems/behaviors/environment:
[checklist value="choking/gasping in sleep|loud snoring|sleep walking|injured self/others when asleep|frequent disturbing nightmares|frequent changes in timing of work shifts|difficulty 'shutting down' mind when it is time for sleep|regularly watch TV/movies and/or play video games less than 1 hr before bedtime|last meal less than 2 hr before bedtime|presence of roommate|presence of bedmate"]
[/conditional]
[checkbox memo="chronic condition HPI add-ons" name="cxcondadd" value=""][conditional field="cxcondadd" condition="(cxcondadd).is('')"][frontload soapnote="sample/drgfms-cxcond-6-conditions-hx-blocks/"][/conditional]