Home Health Intake Report

The patient is a [text name="variable_1" default="-year-old"] [select name="variable_1" value="male|female"] open to home health for the following service: [checkbox name="variable_1" value="medication teaching|wound care|home safety|knee pilot|hip pilot|Skilled Assessment|NPWT"]
Homebound Status: 
[checkbox name="variable_6" value="N/A due to insurance|residual effects of CVA|Leaving home is a taxing effort"]
Pertinent Medical History: 
[checkbox name="variable_2" value="Diabetes|HTN|Heart Failure|CVA|Hemiplegia|Hemiparesis"]
Previous Surgical History: 
[checkbox name="variable_3" value="laparoscopic ABD abscess drainage|Hematoma Evacution|option C"]
Allergies:
[checkbox name= "Allergies" value="PenVK|Moxifloxacin|option C"]
Medication List at SOC: 
[textarea name="variable_1" default="sample text"]

Equipment at home: 
[checkbox name="variable_1" value="Walker|W/C|Shower Chair"]
Plan:
[textarea name="variable_1" default="Wound Note"]
[comment memo="Text that will not show up in output"]
Needed Information from Covering Provider:
[checkbox name="variable_1" value="Wound Measurements|Blood Sugar|Weight|Drain Output|Catheter Status"]
Supplies Needed at Next Visit:
[checkbox name="variable_5" value="Gauze Loaf|Sterile Gauze|Split Gauze|Skin Prep|Saline|Blue Chux|Betadine|Kerlix|Wound Cleanser"]