Subjective/History Elements
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[comment memo="Use with Female GU symptoms Patient Questionnaire"]
[text size="3"]yo [select name="Sex" value="F|M"] (G[text size="3"] P[text size="4"]) with genitourinary symptoms:
[comment memo="Initial questions"]
-Sx include: [checkbox name="GU" value="unusual vaginal bleeding|unusual vaginal discharge|vaginal itching/irritation|vaginal pain|other-"][conditional field="GU" condition="(GU).is('other-')"]
[text size="50"][/conditional]
-Sx started [text size="4"] [select value="day(s)|hour(s)|week(s)|month(s)"] ago
-Sx started when/while [text size="80"]
-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.
-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"]
-Currently pregnant- [select name="pg" value="no|unsure|YES"] [text][conditional field="pg" condition="(pg).is('no')||(pg).is('unsure')"]
-Current contraception method: [checkbox value="Condoms|Withdrawal method|Calendar method (timing intercourse around ovulation)|Birth control pills|Birth control patch (OrthoEvra)|Vaginal ring (NuvaRing)|Injection (DepoProvera)|Diaphragm|Nexplanon|Mirena|Other-"] [text size="30"]
-LMP: [text size="10"][/conditional]
[conditional field="GU" condition="(GU).is('unusual vaginal discharge')||(GU).is('vaginal itching/irritation')"]
[comment memo="Vaginal discharge/itching/irritation questions"]
-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]
[/conditional][conditional field="GU" condition="(GU).is('vaginal pain')"]
[comment memo="Vaginal pain questions"]
-More specific location of vaginal pain: [text memo="ie. inside/outside/etc" size="60"]
-Radiation: [text size="60"]
-Severity currently: [select value="1|2|3|4|5|6|7|8|9|10"]/10
-Severity at worst: [select value="1|2|3|4|5|6|7|8|9|10"]/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]-Other associated symptoms:
--[select value="no|YES"] <-dysuria
--[select value="no|YES"] <-urinary frequency
--[select value="no|YES"] <-hematuria
--[select value="no|YES"] <-decreased appetite
--[select value="no|YES"] <-nausea
--[select value="no|YES"] <-vomiting
--[select value="no|YES"] <-back/flank pain
--[select value="no|yes"] <-pelvic pain
--[select value="no|YES"] <-black or bloody stool
--[select value="no|YES"] <-fever
-Hx of these conditions:
--[select value="no|YES"] <-STD/STI
--[select value="no|YES"] <-Ectopic Pregnancy
--[select value="no|YES"] <-Endometriosis
--[select value="no|YES"] <-Ovarian Cyst
--[select value="no|YES"] <-Kidney Stones
--[select value="no|YES"] <-Urinary Tract Infections
--[select value="no|YES"] <-Diverticulitis
--[select value="no|YES"] <-Diabetes Mellitus
--[select value="no|YES"] <-Candida Vaginitis recent/recurrent
--[select value="no|YES"] <-Bacterial Vaginosis recent/recurrent
--[select value="no|YES"] <-Trichomonas vaginitis
--[select value="no|YES"] <-Atrophic Vaginitis
--[select value="no|YES"] <-PID
--[select value="no|YES"] <-recent new sexual partner
--[select value="no|YES"] <-multiple sexual partners in the past year
-Pertinent Past Surgeries:
--[select value="no|YES"] <-Appendectomy
--[select value="no|YES"] <-Ceserean Section
--[select value="no|YES"] <-Hysterectomy
--[select value="no|YES"] <-Tubal ligation
--[select name="abdsurg" value="no|YES"] <-Other abdominal/pelvic surgeries (see below)
[conditional field="abdsurg" condition="(abdsurg).is('YES')"][textarea memo="other abd/pelv surgeries"][/conditional]

[textarea memo="add'l comments"]
[comment memo="For use in CRDAMC FM Clinic"]
[checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"]
adapted from original contribution by Dr. Scott Moses, creator/author of the Family Practice Notebook [link url="//www.fpnotebook.com" memo="fpnotebook.com"][/conditional]
Use with Female GU symptoms Patient Questionnaire
yo (G P) with genitourinary symptoms:
Initial questions
-Sx include:
-Sx started ago
-Sx started when/while
-Bowel movements/stools consistency usually , and frequency is stool(s) every days.
-Sx improved by
-Sx worsened by
-Since onset, sx have
-Currently pregnant-
-Other associated symptoms:
-- <-dysuria
-- <-urinary frequency
-- <-hematuria
-- <-decreased appetite
-- <-nausea
-- <-vomiting
-- <-back/flank pain
-- <-pelvic pain
-- <-black or bloody stool
-- <-fever
-Hx of these conditions:
-- <-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
-Pertinent Past Surgeries:
-- <-Appendectomy
-- <-Ceserean Section
-- <-Hysterectomy
-- <-Tubal ligation
-- <-Other abdominal/pelvic surgeries (see below)


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