Subjective/History Elements
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[comment memo="Use with GI symptoms Patient Questionnaire"]
[text size="3"]yo [select name="Sex" value="M|F"] with gastrointestinal symptoms:
[comment memo="Initial questions"]
-Sx include: [checkbox name="GI" value="decreased appetite|bloating sensation|pain with defecation|constipation|diarrhea|abdominal pain|nausea/vomiting|other-"][conditional field="GI" condition="(GI).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"]
-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
-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 field="GI" condition="(GI).is('abdominal pain')"][comment memo="Pain specific questions"]
-Location: [text size="50"]
-Radiation: [text size="50"]
-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|other-"] [text size="50"]
[/conditional][conditional field="GI" condition="(GI).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"]
[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][comment memo="Add'l questions"]
-Other Associated Symptoms:
--[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 field="Sex" condition="(Sex).is('F')"]

*[select name="pregnant" value="no|YES"] <-- Patient at risk of potentially being pregnant.[/conditional] [conditional field="pregnant" condition="(pregnant).is('YES')"] Serum HCG test was [select value="ordered|negative|POSITIVE"][/conditional]

[comment memo="For use in CRDAMC FM clinic"]
[checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"]
reference: modified by original contribution from Dr. Scott Moses, creator/author of the [link url="//" memo="(link)"] Family Practice Notebook [/conditional]
Use with GI symptoms Patient Questionnaire
yo with gastrointestinal symptoms:
Initial questions
-Sx include:
-Sx started ago
-Sx started when/while
-Last BM was ago and consistency was , and color was described as .
-#BMs in past 24hrs:
-Last meal eaten was ago
-Sx improved by
-Sx worsened by
-Since onset, sx have
Add'l questions
-Other Associated Symptoms:
-- <-- Chest pain or chest/belly pain with breathing
-- <-- Black or bloody stool
-- <-- Fever
-- <-- Dysuria
-- <-- Urinary frequency
-- <-- Urinary urgency
-- <-- Hematuria

-Hx of these conditions:
-- <-- Gall Bladder or liver disease
-- <-- GERD
-- <-- Peptic ulcer(s)
-- <-- Pancreatitis
-- <-- Kidney stones
-- <-- Urinary tract infections
-- <-- Diverticulitis
-- <-- Inflammatory Bowel Disease
-- <-- Pelvic Infection
-- <-- Vascular disease

-Hx of these surgeries:
-- <-- Appendectomy
-- <-- Cholecystectomy

-Currently using: pertinent meds/substances
-- <-- Daily or near-daily use of NSAIDs
-- <-- Daily or near-daily alcohol use
-- <-- Daily or near-daily use of Opioids
-- <-- aortic aneurysm history or risk (age over 60, tobacco history)

For use in CRDAMC FM clinic
display/hide references
Result - Copy and paste this output: