Subjective/History Elements
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[checkbox name="additionalhx" memo="ADDITIONAL HX" memo_size="large" value=""][conditional field="additionalhx" condition="(additionalhx).is('')"]ADDITIONAL HISTORY:
[checkbox name="addlhxfreetext" memo="freetext" memo_size="small" value=""][/conditional][conditional field="addlhxfreetext" condition="(addlhxfreetext).is('')"][textarea rows="4"][/conditional][conditional field="additionalhx" condition="(additionalhx).is('')"][checkbox name="addlhxformatted" memo="preformatted" memo_size="small" value=""][/conditional][conditional field="addlhxformatted" condition="(addlhxformatted).is('')"][text size="3"] yo [select value="male|female"] additionally reports [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="4"]/10 in severity.
-Describes the character/quality as [checkbox value="sharp|dull|burning|tingling|N/A"][text size="80"].
-These sx [select value="do not travel/radiate|travel/radiate to"] [text size="25"].
-[select name="Associated" value="Denies any associated symptoms.|Reports these associated symptoms that started around the same time-"][/conditional][conditional field="Associated" condition="(Associated).is('Reports these associated symptoms that started around the same time-')"] [text size="25"][/conditional][conditional field="addlhxformatted" condition="(addlhxformatted).is('')"]
-Symptoms are improved with [text size ="80"].
-Symptoms are worsened by [text size="80"].
-Patient [select value="denies|admits to"] history of similar symptoms previously.[/conditional][conditional field="additionalhx" condition="(additionalhx).is('')"]

[/conditional][checkbox name="MasterROS" memo="ROS" memo_size="large" value=""][conditional field="MasterROS" condition="(MasterROS).is('')"]ADDITIONAL REVIEW OF SYSTEMS:
[checkbox memo="Constitutional" name="Constitutional" value=""][/conditional][conditional field="Constitutional" condition="(Constitutional).is('')"]-Constitutional- [checkbox name="Constitutional1" value="fever"][/conditional][conditional field="Constitutional1" condition="(Constitutional1).is('fever')"]->[select value="(-)|{+}"], [/conditional][conditional field="Constitutional" condition="(Constitutional).is('')"][checkbox name="Constitutional2" value="chills"][/conditional][conditional field="Constitutional2" condition="(Constitutional2).is('chills')"]->[select value="(-)|{+}"], [/conditional][conditional field="Constitutional" condition="(Constitutional).is('')"][checkbox name="Constitutional3" value="malaise"][/conditional][conditional field="Constitutional3" condition="(Constitutional3).is('malaise')"]->[select value="(-)|{+}"], [/conditional][conditional field="Constitutional" condition="(Constitutional).is('')"][checkbox name="Constitutional4" value="unexplained wt gain/loss"][/conditional][conditional field="Constitutional4" condition="(Constitutional4).is('unexplained wt gain/loss')"]->[select value="(-)|{+}"][/conditional][conditional field="Constitutional" condition="(Constitutional).is('')"][checkbox name="Constitutional5" memo="freetext" memo_size="small" value=""][/conditional][conditional field="Constitutional5" condition="(Constitutional5).is('')"]
--[textarea memo="explanation of abnormals if needed" memo_size="small" memo_color="orange" rows="2"][/conditional][conditional field="Constitutional" condition="(Constitutional).is('')"]
[/conditional][conditional field="MasterROS" condition="(MasterROS).is('')"][checkbox memo="HEENT" name="HEENT" value=""][/conditional][conditional field="HEENT" condition="(HEENT).is('')"]-HEENT- [checkbox name="HEENT1" value="vision/hearing/smell changes"][/conditional][conditional field="HEENT1" condition="(HEENT1).is('vision/hearing/smell changes')"]->[select value="(-)|{+}"], [/conditional][conditional field="HEENT" condition="(HEENT).is('')"][checkbox name="HEENT2" value="nose/throat/neck symptoms"][/conditional][conditional field="HEENT2" condition="(HEENT2).is('nose/throat/neck symptoms')"]->[select value="(-)|{+}"][/conditional][conditional field="HEENT" condition="(HEENT).is('')"][checkbox name="HEENT3" memo="freetext" memo_size="small" value=""][/conditional][conditional field="HEENT3" condition="(HEENT3).is('')"]
--[textarea memo="explanation of abnormals if needed" memo_size="small" memo_color="orange" rows="2"][/conditional][conditional field="HEENT" condition="(HEENT).is('')"]
[/conditional][conditional field="MasterROS" condition="(MasterROS).is('')"][checkbox memo="Resp" name="Resp" value=""][/conditional][conditional field="Resp" condition="(Resp).is('')"]-Resp- [checkbox name="Resp1" value="cough"][/conditional][conditional field="Resp1" condition="(Resp1).is('cough')"]->[select value="(-)|{+}"], [/conditional][conditional field="Resp" condition="(Resp).is('')"][checkbox name="Resp2" value="SOB"][/conditional][conditional field="Resp2" condition="(Resp2).is('SOB')"]->[select value="(-)|{+}"], [/conditional][conditional field="Resp" condition="(Resp).is('')"][checkbox name="Resp3" memo="freetext" memo_size="small" value=""][/conditional][conditional field="Resp3" condition="(Resp3).is('')"]
--[textarea memo="explanation of abnormals if needed" memo_size="small" memo_color="orange" rows="2"][/conditional][conditional field="Resp" condition="(Resp).is('')"]
[/conditional][conditional field="MasterROS" condition="(MasterROS).is('')"][checkbox memo="CV" name="CV" value=""][/conditional][conditional field="CV" condition="(CV).is('')"]-CV- [checkbox name="CV1" value="chest pain"][/conditional][conditional field="CV1" condition="(CV1).is('chest pain')"]->[select value="(-)|{+}"], [/conditional][conditional field="CV" condition="(CV).is('')"][checkbox name="CV2" value="palpitations"][/conditional][conditional field="CV2" condition="(CV2).is('palpitations')"]->[select value="(-)|{+}"][/conditional][conditional field="CV" condition="(CV).is('')"][checkbox name="CV3" memo="freetext" memo_size="small" value=""][/conditional][conditional field="CV3" condition="(CV3).is('')"]
--[textarea memo="explanation of abnormals if needed" memo_size="small" memo_color="orange" rows="2"][/conditional][conditional field="CV" condition="(CV).is('')"]
[/conditional][conditional field="MasterROS" condition="(MasterROS).is('')"][checkbox memo="GI" name="GI" value=""][/conditional][conditional field="GI" condition="(GI).is('')"]-GI- [checkbox name="GI1" value="abdominal pain"][/conditional][conditional field="GI1" condition="(GI1).is('abdominal pain')"]->[select value="(-)|{+}"], [/conditional][conditional field="GI" condition="(GI).is('')"][checkbox name="GI2" value="nausea"][/conditional][conditional field="GI2" condition="(GI2).is('nausea')"]->[select value="(-)|{+}"], [/conditional][conditional field="GI" condition="(GI).is('')"][checkbox name="GI3" value="vomiting"][/conditional][conditional field="GI3" condition="(GI3).is('vomiting')"]->[select value="(-)|{+}"], [/conditional][conditional field="GI" condition="(GI).is('')"][checkbox name="GI4" value="diarrhea"][/conditional][conditional field="GI4" condition="(GI4).is('diarrhea')"]->[select value="(-)|{+}"], [/conditional][conditional field="GI" condition="(GI).is('')"][checkbox name="GI5" value="constipation"][/conditional][conditional field="GI5" condition="(GI5).is('constipation')"]->[select value="(-)|{+}"][/conditional][conditional field="GI" condition="(GI).is('')"][checkbox name="GI6" memo="freetext" memo_size="small" value=""][/conditional][conditional field="GI6" condition="(GI6).is('')"]
--[textarea memo="explanation of abnormals if needed" memo_size="small" memo_color="orange" rows="2"][/conditional][conditional field="GI" condition="(GI).is('')"]
[/conditional][conditional field="MasterROS" condition="(MasterROS).is('')"][checkbox memo="GU" name="GU" value=""][/conditional][conditional field="GU" condition="(GU).is('')"]-GU- [checkbox name="GU1" value="urinary frequency"][/conditional][conditional field="GU1" condition="(GU1).is('urinary frequency')"]->[select value="(-)|{+}"], [/conditional][conditional field="GU" condition="(GU).is('')"][checkbox name="GU2" value="urinary urgency"][/conditional][conditional field="GU2" condition="(GU2).is('urinary urgency')"]->[select value="(-)|{+}"], [/conditional][conditional field="GU" condition="(GU).is('')"][checkbox name="GU3" value="pain with voiding"][/conditional][conditional field="GU3" condition="(GU3).is('pain with voiding')"]->[select value="(-)|{+}"], [/conditional][conditional field="GU" condition="(GU).is('')"][checkbox name="GU4" value="penile discharge"][/conditional][conditional field="GU4" condition="(GU4).is('penile discharge')"]->[select value="(-)|{+}"], [/conditional][conditional field="GU" condition="(GU).is('')"][checkbox name="GU5" value="vaginal discharge"][/conditional][conditional field="GU5" condition="(GU5).is('vaginal discharge')"]->[select value="(-)|{+}"], [/conditional][conditional field="GU" condition="(GU).is('')"][checkbox name="GU6" value="dyspareunia"][/conditional][conditional field="GU6" condition="(GU6).is('dyspareunia')"]->[select value="(-)|{+}"][/conditional][conditional field="GU" condition="(GU).is('')"][checkbox name="GU7" memo="freetext" memo_size="small" value=""][/conditional][conditional field="GU7" condition="(GU7).is('')"]
--[textarea memo="explanation of abnormals if needed" memo_size="small" memo_color="orange" rows="2"][/conditional][conditional field="GU" condition="(GU).is('')"]
[/conditional][conditional field="MasterROS" condition="(MasterROS).is('')"][checkbox memo="MSK" name="MSK" value=""][/conditional][conditional field="MSK" condition="(MSK).is('')"]-MSK- [checkbox name="MSK1" value="new/unusual muscle aches/pains"][/conditional][conditional field="MSK1" condition="(MSK1).is('new/unusual muscle aches/pains')"]->[select value="(-)|{+}"][/conditional][conditional field="MSK" condition="(MSK).is('')"][conditional field="MSK" condition="(MSK).is('')"][checkbox name="MSK2" memo="freetext" memo_size="small" value=""][/conditional][conditional field="MSK2" condition="(MSK2).is('')"]
--[textarea memo="explanation of abnormals if needed" memo_size="small" memo_color="orange" rows="2"][/conditional][conditional field="MSK" condition="(MSK).is('')"]
[/conditional][conditional field="MasterROS" condition="(MasterROS).is('')"][checkbox memo="Neuro" name="Neuro" value=""][/conditional][conditional field="Neuro" condition="(Neuro).is('')"]-Neuro- [checkbox name="Neuro1" value="dizziness"][/conditional][conditional field="Neuro1" condition="(Neuro1).is('dizziness')"]->[select value="(-)|{+}"], [/conditional][conditional field="Neuro" condition="(Neuro).is('')"][checkbox name="Neuro2" value="weakness"][/conditional][conditional field="Neuro2" condition="(Neuro2).is('weakness')"]->[select value="(-)|{+}"], [/conditional][conditional field="Neuro" condition="(Neuro).is('')"][checkbox name="Neuro3" value="imbalance"][/conditional][conditional field="Neuro3" condition="(Neuro3).is('imbalance')"]->[select value="(-)|{+}"], [/conditional][conditional field="Neuro" condition="(Neuro).is('')"][checkbox name="Neuro4" value="numbness"][/conditional][conditional field="Neuro4" condition="(Neuro4).is('numbness')"]->[select value="(-)|{+}"], [/conditional][conditional field="Neuro" condition="(Neuro).is('')"][checkbox name="Neuro5" value="tingling"][/conditional][conditional field="Neuro5" condition="(Neuro5).is('tingling')"]->[select value="(-)|{+}"], [/conditional][conditional field="Neuro" condition="(Neuro).is('')"][checkbox name="Neuro6" value="swallowing difficulty"][/conditional][conditional field="Neuro6" condition="(Neuro6).is('swallowing difficulty')"]->[select value="(-)|{+}"][/conditional][conditional field="Neuro" condition="(Neuro).is('')"][checkbox name="Neuro7" memo="freetext" memo_size="small" value=""][/conditional][conditional field="Neuro7" condition="(Neuro7).is('')"]
--[textarea memo="explanation of abnormals if needed" memo_size="small" memo_color="orange" rows="2"][/conditional][conditional field="Neuro" condition="(Neuro).is('')"]
[/conditional][conditional field="MasterROS" condition="(MasterROS).is('')"]

[/conditional][checkbox memo="PHQ-9" name="PHQ9" value=""][conditional field="PHQ9" condition="(PHQ9).is('')"]Patient Health Questionnaire PHQ-9 - Depression Screen
[select name="phqQ1" value="not at all (0 points)=0|several days (1 point)=1|more than half the days (2 points)=2|nearly every day (3 points)=3"] <-- #1 Little interest or pleasure in doing things over the last 2 weeks
[select name="phqQ2" value="not at all (0 points)=0|several days (1 point)=1|more than half the days (2 points)=2|nearly every day (3 points)=3"] <-- #2 Feeling down, depressed or hopeless over the last 2 weeks
[select name="phqQ3" value="not at all (0 points)=0|several days (1 point)=1|more than half the days (2 points)=2|nearly every day (3 points)=3"] <-- #3 Trouble falling or staying asleep, or sleeping too much over the last weeks
[select name="phqQ4" value="not at all (0 points)=0|several days (1 point)=1|more than half the days (2 points)=2|nearly every day (3 points)=3"] <-- #4 Feeling tired or having little energy over the last 2 weeks
[select name="phqQ5" value="not at all (0 points)=0|several days (1 point)=1|more than half the days (2 points)=2|nearly every day (3 points)=3"] <-- #5 Poor appetite or overeating over the last 2 weeks
[select name="phqQ6" value="not at all (0 points)=0|several days (1 point)=1|more than half the days (2 points)=2|nearly every day (3 points)=3"] <-- #6 Feeling bad about self-or are a failure or have let self or family down over the last 2 weeks
[select name="phqQ7" value="not at all (0 points)=0|several days (1 point)=1|more than half the days (2 points)=2|nearly every day (3 points)=3"] <-- #7 Trouble concentrating on things, such as reading the newspaper or watching television over the last 2 weeks
[select name="phqQ8" value="not at all (0 points)=0|several days (1 point)=1|more than half the days (2 points)=2|nearly every day (3 points)=3"] <-- #8 Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that has been moving around a lot more than usual over the last 2 weeks
[select name="phqQ9" value="not at all (0 points)=0|several days (1 point)=1|more than half the days (2 points)=2|nearly every day (3 points)=3"] <-- #9 Thoughts that would be better off dead or of hurting self in some way over the last 2 weeks
Score --> [calc value="score=(phqQ1)+(phqQ2)+(phqQ3)+(phqQ4)+(phqQ5)+(phqQ6)+(phqQ7)+(phqQ8)+(phqQ9)" memo="score"] out of 27 points. Interpretation --> [calc value="score=(phqQ1)+(phqQ2)+(phqQ3)+(phqQ4)+(phqQ5)+(phqQ6)+(phqQ7)+(phqQ8)+(phqQ9);score>20?'Severe':score>14?'Moderately Severe':score>9?'Mild':score>4?'Minimal Symptoms':'Asymptomatic'" memo="interpretation"]
[checkbox memo="display/hide references" name="footnotesPHQ9" value=""][/conditional][conditional field="footnotesPHQ9" condition="(footnotesPHQ9).is('')"]
reference: [link url="http://www.ncbi.nlm.nih.gov/pubmed/11556941" memo="#1"] Kroenke (2001) J Gen Intern Med 16:606-13.

[/conditional][checkbox memo="GAD-7" name="GAD7" value=""][conditional field="GAD7" condition="(GAD7).is('')"]GAD-7 Questionnaire
[select name="gadQ1" value="Not at all (0 points)=0|Several days (1 points)=1|More than half the days (2 points)=2|Nearly everyday (3 points)=3"] <-- Feeling nervous, anxious or on edge (over the last two weeks)?
[select name="gadQ2" value="Not at all (0 points)=0|Several days (1 points)=1|More than half the days (2 points)=2|Nearly everyday (3 points)=3"] <-- Being unable to stop or control worrying (over the last two weeks)?
[select name="gadQ3" value="Not at all (0 points)=0|Several days (1 points)=1|More than half the days (2 points)=2|Nearly everyday (3 points)=3"] <-- Worrying too much about different things (over the last two weeks)?
[select name="gadQ4" value="Not at all (0 points)=0|Several days (1 points)=1|More than half the days (2 points)=2|Nearly everyday (3 points)=3"] <-- Having trouble relaxing (over the last two weeks)?
[select name="gadQ5" value="Not at all (0 points)=0|Several days (1 points)=1|More than half the days (2 points)=2|Nearly everyday (3 points)=3"] <-- Being so restless that it is hard to sit still (over the last two weeks)?
[select name="gadQ6" value="Not at all (0 points)=0|Several days (1 points)=1|More than half the days (2 points)=2|Nearly everyday (3 points)=3"] <-- Becoming easily annoyed or irritable (over the last two weeks)?
[select name="gadQ7" value="Not at all (0 points)=0|Several days (1 points)=1|More than half the days (2 points)=2|Nearly everyday (3 points)=3"] <-- Feeling afraid, as if something awful might happen (over the last two weeks)?
Score --> [calc value="score=(gadQ1)+(gadQ2)+(gadQ3)+(gadQ4)+(gadQ5)+(gadQ6)+(gadQ7)" memo="score"] out of 21 points
Interpretation --> [calc value="score=(gadQ1)+(gadQ2)+(gadQ3)+(gadQ4)+(gadQ5)+(gadQ6)+(gadQ7);score>8?'suggestive of anxiety or panic disorder':score>0?'mild symptoms':'asymptomatic'" memo="interpretation"]
[checkbox memo="references" name="gad7footnotes" value=""][/conditional][conditional field="gad7footnotes" condition="(gad7footnotes).is('')"]references:
[link url="http://www.ncbi.nlm.nih.gov/pubmed/16717171" memo="#1"] Spitzer RL, Kroenke K, Williams JB, Löwe B. Arch Intern Med. 2006 May 22;166(10):1092-7. A brief measure for assessing generalized anxiety disorder: the GAD-7
[link url="http://www.aafp.org/afp/2008/0815/p501.html" memo="#2"] Am Fam Physician. 2008 Aug 15;78(4):501-502

[/conditional][checkbox memo="Adult ASRS (ADHD) Initial Questionnaire" name="ASRSinitial" value=""][conditional field="ASRSinitial" condition="(ASRSinitial).is('')"]Adult ADHD Self-Report Scale
Section A (SCREEN)
[select name="asrsQ1" value="never=0|rarely=0|sometimes=1|often=1|very often=1"] <-- 1. Trouble wrapping up the final details of a project, once the challenging parts have been done?
[select name="asrsQ2" value="never=0|rarely=0|sometimes=1|often=1|very often=1"] <-- 2. Difficulty getting things in order when you have to do a task that requires organization?
[select name="asrsQ3" value="never=0|rarely=0|sometimes=1|often=1|very often=1"] <-- 3. Problems remembering appointments or obligations?
[select name="asrsQ4" value="never=0|rarely=0|sometimes=0|often=1|very often=1"] <-- 4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
[select name="asrsQ5" value="never=0|rarely=0|sometimes=0|often=1|very often=1"] <-- 5. Fidget or squirm with your hands or feet when you have to sit down for a long time?
[select name="asrsQ6" value="never=0|rarely=0|sometimes=0|often=1|very often=1"] <-- 6. Feel overly active and compelled to do things, like you were driven by a motor?

[checkbox name="ASRSseverity" value="" memo="Complete and score Section B (SEVERITY) if above screen positive"][/conditional][conditional field="ASRSseverity" condition="(ASRSseverity).is('')"]
Section B (SEVERITY)
[select name="asrsQ7" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 7. Make careless mistakes when you have to work on a boring or difficult project?
[select name="asrsQ8" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 8. Difficulty keeping your attention when you are doing boring or repetitive work?
[select name="asrsQ9" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 9. Difficulty concentrating on what people say to you, even when they are speaking to you directly?
[select name="asrsQ10" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 10. Misplace or have difficulty finding things at home or at work?
[select name="asrsQ11" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 11. Distracted by activity or noise around you?
[select name="asrsQ12" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 12. Leave your seat in meetings or other situations in which you are expected to remain seated?
[select name="asrsQ13" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 13. Feel restless or fidgety?
[select name="asrsQ14" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 14. Difficulty unwinding and relaxing when you have time to yourself?
[select name="asrsQ15" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 15. Talking too much when you are in social situations?
[select name="asrsQ16" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 16. Finishing the sentences of the people you are talking to, before they can finish them themselves?
[select name="asrsQ17" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 17. Difficulty waiting your turn in situations when turn taking is required?
[select name="asrsQ18" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 18. Interrupt others when they are busy?

[/conditional][conditional field="ASRSinitial" condition="(ASRSinitial).is('')"]Section A (SCREEN) Result –-> [calc value="score1=(asrsQ1)+(asrsQ2)+(asrsQ3)+(asrsQ4)+(asrsQ5)+(asrsQ6);score1>3?'Section A - Symptoms highly consistent with ADHD in adults, further investigation is warranted':'Section A - Negative screen for ADHD, consider other diagnoses'" memo="interpretation" memo_size="small" ][/conditional][conditional field="ASRSseverity" condition="(ASRSseverity).is('')"]

Section B (SEVERITY) Result --> [calc value="score2=+(asrsQ7)+(asrsQ8)+(asrsQ9)+(asrsQ10)+(asrsQ11)+(asrsQ12)+(asrsQ13)+(asrsQ14)+(asrsQ15)+(asrsQ16)+(asrsQ17)+(asrsQ18);score2>47?'Section B - Average frequency of symptoms = VERY OFTEN':score2>35?'Section B - Average frequency of symptoms = OFTEN':score2>23?'Section B - Average frequency of symptoms = SOMETIMES':score2>11?'Section B - Average frequency of symptoms = RARELY':'Section B - Average frequency of symptoms = NEVER'" memo="interpretation"][/conditional][conditional field="ASRSinitial" condition="(ASRSinitial).is('')"]
[checkbox memo="references" name="ASRSfootnotes" value=""]

[/conditional][conditional field="ASRSfootnotes" condition="(ASRSfootnotes).is('')"]reference:
[link url="//www.ncbi.nlm.nih.gov/pubmed/15841682" memo="#1"] Kessler RC, Adler L, Ames M, Demler O, Faraone S, Hiripi E, Howes MJ, Jin R, Secnik K, Spencer T, Ustun TB, Walters EE. The World Health Organization Adult ADHD Self-Report Scale (ASRS): a short screening scale for use in the general population. Psychol Med. 2005 Feb;35(2):245-56.
[link url="http://www.aafp.org/afp/2012/0501/p890.html memo="#2"] Post RE, Kurlansik SL. Diagnosis and Management of Attention-Deficit/Hyperactivity Disorder in Adults. Am Fam Phys. 2012 May 1;85(9):890-896.

[/conditional][checkbox memo="Adult followup ASRS Questionnaire" name="ASRSfollowup" value=""][conditional field="ASRSfollowup" condition="(ASRSfollowup).is('')"]Adult ADHD Self-Report Scale

[select name="asrsfuQ7" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 7. Make careless mistakes when you have to work on a boring or difficult project?
[select name="asrsfuQ8" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 8. Difficulty keeping your attention when you are doing boring or repetitive work?
[select name="asrsfuQ9" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 9. Difficulty concentrating on what people say to you, even when they are speaking to you directly?
[select name="asrsfuQ10" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 10. Misplace or have difficulty finding things at home or at work?
[select name="asrsfuQ11" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 11. Distracted by activity or noise around you?
[select name="asrsfuQ12" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 12. Leave your seat in meetings or other situations in which you are expected to remain seated?
[select name="asrsfuQ13" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 13. Feel restless or fidgety?
[select name="asrsfuQ14" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 14. Difficulty unwinding and relaxing when you have time to yourself?
[select name="asrsfuQ15" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 15. Talking too much when you are in social situations?
[select name="asrsfuQ16" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 16. Finishing the sentences of the people you are talking to, before they can finish them themselves?
[select name="asrsfuQ17" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 17. Difficulty waiting your turn in situations when turn taking is required?
[select name="asrsfuQ18" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 18. Interrupt others when they are busy?

Result --> [calc value="score2=+(asrsfuQ7)+(asrsfuQ8)+(asrsfuQ9)+(asrsfuQ10)+(asrsfuQ11)+(asrsfuQ12)+(asrsfuQ13)+(asrsfuQ14)+(asrsfuQ15)+(asrsfuQ16)+(asrsfuQ17)+(asrsfuQ18);score2>47?'Section B - Average frequency of symptoms = VERY OFTEN':score2>35?'Section B - Average frequency of symptoms = OFTEN':score2>23?'Section B - Average frequency of symptoms = SOMETIMES':score2>11?'Section B - Average frequency of symptoms = RARELY':'Section B - Average frequency of symptoms = NEVER'" memo="interpretation"]
[checkbox memo="references" name="asrsfufootnotes" value=""]

[/conditional][conditional field="asrsfufootnotes" condition="(asrsfufootnotes).is('')"]
reference:
[link url="//www.ncbi.nlm.nih.gov/pubmed/15841682" memo="#1"] Kessler RC, Adler L, Ames M, Demler O, Faraone S, Hiripi E, Howes MJ, Jin R, Secnik K, Spencer T, Ustun TB, Walters EE. The World Health Organization Adult ADHD Self-Report Scale (ASRS): a short screening scale for use in the general population. Psychol Med. 2005 Feb;35(2):245-56.
[link url="http://www.aafp.org/afp/2012/0501/p890.html memo="#2"] Post RE, Kurlansik SL. Diagnosis and Management of Attention-Deficit/Hyperactivity Disorder in Adults. Am Fam Phys. 2012 May 1;85(9):890-896.

[/conditional][checkbox memo="Asthma Severity Classification" name="AsthmaSeverity" value=""][conditional field="AsthmaSeverity" condition="(AsthmaSeverity).is('')"]Asthma Severity Classification[/comment memo="For patients NOT currently taking long-term control medication"]
[select name="asthmasevAge" value="|5 to 11 years|12 years and above"] <-- Age
[/conditional][conditional field="asthmasevAge" condition="(asthmasevAge).is('5 to 11 years')"][select name="asthmasevImpSymp1" value="Up to 2 days per week=1|More than 2 days per week, but not daily=10|Daily=100|Throughout the day=1000"] <-- Impairment - Symptoms
[select name="asthmasevImpNA1" value="Up to 2 times per month=1|3 to 4 times per month=10|More than 1 time per week, but not nightly=100|Often 7 times a week=1000"] <-- Impairment - Nighttime awakenings
[select name="asthmasevImpSA1" value="Up to 2 days per week=1|More than 2 days per week, but not daily=10|Daily=100|Several times per day=1000"] <-- Impairment - Short-acting beta2-agonist use for symptom control (not prevention of exercise induced bronchospasm)
[select name="asthmasevImpNorm1" value="None=1|Minor limitation=10|Some limitation=100|Extremely limited=1000"] <-- Impairment - Interference with normal activity
[select name="asthmasevImpLF1" value="Normal FEV1 between exacerbations, FEV1 more than 80% predicted, FEV1 to FVC more than 85%=1|FEV1 80% or more than predicted, FEV1 to FVC more than 80%=10|FEV1 60 to 80% predicted, FEV1 to FVC 75 to 80% predicted=100|FEV1 less than 60% predicted, FEV1 to FVC less than 75% predicted=1000"] <-- Impairment - Lung function
[select name="asthmasevRisk1" value="0 to 1 per year=1|2 or more per year=10"] <-- Risk - Exacerbations requiring oral systemic corticosteroids
Interpretation --> [calc memo="Severity" value="score1=(asthmasevImpSymp1)+(asthmasevImpNA1)+(asthmasevImpSA1)+(asthmasevImpNorm1)+(asthmasevImpLF1)+(asthmasevRisk1);score1>999?'Severe Persistent Asthma':score1>99?'Moderate Persistent Asthma':score1>9?'Mild Persistent Asthma':'Intermittent Asthma'"]
[link url="/wp-content/uploads/2018/08/asthma-steps-kids.jpg" memo="Stepwise medication table for children 5-11 years"][/conditional][conditional field="asthmasevAge" condition="(asthmasevAge).is('12 years and above')"][select name="asthmasevImpSymp2" value="Up to 2 days per week=1|More than 2 days per week, but not daily=10|Daily=100|Throughout the day=1000"] <-- Impairment - Symptoms
[select name="asthmasevImpNA2" value="Up to 2 times per month=1|3 to 4 times per month=10|More than 1 time per week, but not nightly=100|Often 7 times per week=1000"] <-- Impairment - Nighttime awakenings
[select name="asthmasevImpSA2" value="Up to 2 days per week=1|More than 2 days per week but not daily, and not more than 1 time on any day=10|Daily=100|Several times per day=1000"] <-- Impairment - Short-acting beta2-agonist use for symptom control (not prevention of exercise induced bronchospasm)
[select name="asthmasevImpNorm2" value="None=1|Minor limitation=10|Some limitation=100|Extremely limited=1000"] <-- Impairment - Interference with normal activity
[select name="asthmasevImpLF2" value="Normal FEV1 between exacerbations, FEV1 more than 80% predicted, FEV1 to FVC normal=1|FEV1 80% or more than predicted, FEV1 to FVC normal=10|FEV1 more than 60% but less than 80%, FEV1 to FVC reduced 5%=100|FEV1 less than 60% predicted, FEV1 to FVC reduced more than 5%=1000"] <-- Impairment - Lung function
Normal FEV1/FVC: 8-19 yr 85 percent; 20-39 yr 80 percent; 40-59 yr 75 percent; 60-80 yr 70 percent
[select name="asthmasevRisk2" value="0 to 1 per year=1|2 or more per year=10"] <-- Risk - Exacerbations requiring oral systemic corticosteroids
Interpretation --> [calc memo="Severity" value="score2=(asthmasevImpSymp2)+(asthmasevImpNA2)+(asthmasevImpSA2)+(asthmasevImpNorm2)+(asthmasevImpLF2)+(asthmasevRisk2);score2>999?'Severe Persistent Asthma':score2>99?'Moderate Persistent Asthma':score2>9?'Mild Persistent Asthma':'Intermittent Asthma'"]
[link url="/wp-content/uploads/2018/08/asthma-steps-adults.jpg" memo="Stepwise medication table for ages 12+ years"][/conditional][conditional field="AsthmaSeverity" condition="(AsthmaSeverity).is('')"]
[checkbox memo="display/hide references" name="footnotes" value=""]

[conditional field="footnotes" condition="(footnotes).is('')"]
reference:
[link url="//www.nhlbi.nih.gov/health-topics/guidelines-for-diagnosis-management-of-asthma" memo="#1"] National Asthma Education and Prevention Program (NAEPP) Coordinating Committee (CC) 2007 Guidelines 2007 Guidelines
[link url="//www.ncbi.nlm.nih.gov/pubmed/20141095" memo="#2"] Pollart (2009) Am Fam Physician 79: 761-7.

[/conditional][checkbox memo="Asthma Control Classification & Recommendations" name="AsthmaControl" value=""][conditional field="AsthmaControl" condition="(AsthmaControl).is('')"]Asthma Control Classification & Recommendations[comment memo="for patients currently taking long-term control medication" memo_size="small"]
[select name="asthmacontrAge" value="|5 to 11 years|12 years and above"] <-- Age
[/conditional][conditional field="asthmacontrAge" condition="(asthmacontrAge).is('5 to 11 years')"][select name="asthmacontrImpSymp1" value="Up to 2 days per week, but not more than once on each day=1|More than 2 days per week or multiple times on up to 2 days per week=10|Throughout the day=100"] <-- Impairment - Symptoms
[select name="asthmacontrImpNA1" value="Up to 1 time per month=1|2 or more times per month=10|2 or more times per week=100"] <-- Impairment - Nighttime awakenings
[select name="asthmacontrImpSA1" value="Up to 2 days per week=1|More than 2 days per week=10|Several times per day=100"] <-- Impairment - Short-acting beta2-agonist use for symptom control (not prevention of exercise induced bronchospasm)
[select name="asthmacontrImpNorm1" value="None=1|Some limitation=10|Extremely limited=100"] <-- Impairment - Interference with normal activity
[select name="asthmacontrImpLF1" value="FEV1 more than 80% predicted, Peak Flow more than 80% personal best, FEV1 to FVC more than 80%=1|FEV1 60 to 80% predicted, Peak Flow 60 to 80% personal best, FEV1 to FVC 75 to 80%=10|FEV1 less than 60% predicted, Peak Flow less than 60% personal best, FEV1 to FVC less than 75%=100"] <-- Impairment - Lung Function
[select name="asthmacontrRisk1" value="0 to 1 per year=1|2 or more per year=10"] <-- Risk - Exacerbations requiring oral systemic corticosteroids
Recommendations --> [calc memo="Interpretation" value="score1=(asthmacontrImpSymp1)+(asthmacontrImpNA1)+(asthmacontrImpSA1)+(asthmacontrImpNorm1)+(asthmacontrImpLF1)+(asthmacontrRisk1);score1>99?'Very Poorly Controlled Asthma: Consider short course of oral systemic corticosteroids; step up one to two steps, and reevaluate in two weeks.':score1>9?'Not Well-Controlled Asthma: Step up one step and reevaluate in two to six weeks.':'Well-Controlled Asthma: Maintain current step; regular follow-up every one to six months to maintain control; consider step down if well controlled for at least three months.'"]
[link memo="Stepwise medication table for children 5-11 years" url="//www.soapnote.org/wp-content/uploads/2018/08/asthma-steps-kids.jpg"]
[/conditional][conditional field="asthmacontrAge" condition="(asthmacontrAge).is('12 years and above')"][select name="asthmacontrImpSymp2" value="Up to 2 days per week=1|More than 2 days per week=10|Throughout the day=100"] <-- Impairment - Symptoms
[select name="asthmacontrImpNA2" value="Up to 2 times per month=1|1 to 3 times per week=10|4 or more times per week=100"] <-- Impairment - Nighttime awakenings
[select name="asthmacontrImpSA2" value="Up to 2 days per week=1|More than 2 days per week=10|Several times per day=100"] <-- Impairment - Short-acting beta2-agonist use for symptom control (not prevention of exercise induced bronchospasm)
[select name="asthmacontrImpNorm2" value="None=1|Some limitation=10|Extremely limited=100"] <-- Impairment - Interference with normal activity
[select name="asthmacontrImpLF2" value="FEV1 more than 80% predicted, Peak Flow more than 80% personal best=1|FEV1 60 to 80% predicted, Peak Flow 60 to 80% personal best=10|FEV1 less than 60% predicted, Peak Flow less than 60% personal best=100"] <-- Impairment - Lung Function
[select name="asthmacontrImpQ2" value="ATAQ of 0 OR ACQ less than or equal to 0.75 OR ACT greater than or equal to 20 OR soapnote Generic equal to 0=1|ATAQ of 1 to 2 OR ACQ greater than or equal to 1.5 OR ACT of 16 to 19 OR soapnote Generic greater than or equal to 1=10|ATAQ of 3 to 4 OR ACT less than or equal to 15=100"] <-- Impairment - Questionnaires
[select name="asthmacontrRisk2" value="0 to 1 per year=1|2 or more per year=10"] <-- Risk - Exacerbations requiring oral systemic corticosteroids
Recommendations --> [calc memo="Interpretation" value="score2=(asthmacontrImpSymp2)+(asthmacontrImpNA2)+(asthmacontrImpSA2)+(asthmacontrImpNorm2)+(asthmacontrImpLF2)+(asthmacontrImpQ2)+(asthmacontrRisk2);score2>99?'Very Poorly Controlled Asthma: Consider short course of oral systemic corticosteroids; step up one to two steps, and reevaluate in two weeks.':score2>9?'Not Well-Controlled Asthma: Step up one step and reevaluate in two to six weeks.':'Well-Controlled Asthma: Maintain current step; regular follow-up every one to six months to maintain control; consider step down if well controlled for at least three months.'"]
[link memo="Stepwise medication table for ages 12+ years" url="//www.soapnote.org/wp-content/uploads/2018/08/asthma-steps-adults.jpg"]

[/conditional][conditional field="AsthmaControl" condition="(AsthmaControl).is('')"]
[checkbox memo="references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"]reference:
[link url="//www.nhlbi.nih.gov/health-topics/guidelines-for-diagnosis-management-of-asthma" memo="#1"] National Asthma Education and Prevention Program (NAEPP) Coordinating Committee (CC) 2007 Guidelines 2007 Guidelines
[link url="//www.ncbi.nlm.nih.gov/pubmed/20141095" memo="#2"] Pollart (2009) Am Fam Physician 79: 761-7.

[/conditional]
ADDITIONAL HX ROS PHQ-9 GAD-7 Adult ASRS (ADHD) Initial Questionnaire Adult followup ASRS Questionnaire Asthma Severity Classification Asthma Control Classification & Recommendations

Result - Copy and paste this output: