Medic/Nurse/Scribe History – Adult Chronic/Followup Visits

Medic/Nurse/Scribe History - Adult Chronic/Followup Visits
[checkbox memo="if not already inputted" memo_size="small" name="Vitals" value="Vital signs:"][conditional field="Vitals" condition="(Vitals).is('Vital signs:')"] HR [text size="5"]; SpO2 [text size="5"]; [checkbox name="Temp" value="Temp"][/conditional][conditional field="Temp" condition="(Temp).is('Temp')"] [text size="5"] deg F; [/conditional][conditional field="Vitals" condition="(Vitals).is('Vital signs:')"][checkbox name="BP" value="BP"][/conditional][conditional field="BP" condition="(BP).is('BP')"] [text size="5"] / [text size="5"] mmHg; [/conditional][conditional field="Vitals" condition="(Vitals).is('Vital signs:')"][checkbox name="RR" value="RR"][/conditional][conditional field="RR" condition="(RR).is('RR')"] [text size="5"] breaths/min; [/conditional][conditional field="Vitals" condition="(Vitals).is('Vital signs:')"][checkbox name="HT" value="HT"][/conditional][conditional field="HT" condition="(HT).is('HT')"] [text size="5"] [select value="in|cm"]; [/conditional][conditional field="Vitals" condition="(Vitals).is('Vital signs:')"][checkbox name="WT" value="WT"][/conditional][conditional field="WT" condition="(WT).is('WT')"] [text size="5"] [select value="lbs|kg"][/conditional][conditional field="Vitals" condition="(Vitals).is('Vital signs:')"]

[/conditional][comment memo="*" memo_color="blue" memo_size="small"]HPI: [text size="5"] yo [select name="Gender" value="|M|F"] here for-

[checkbox memo="#1" memo_size="small" name="chr1" value="-Chronic Condition-"][conditional field="chr1" condition="(chr1).is('-Chronic Condition-')"] [text memo="freetext or select one" memo_size="small" size="70"][select value="|Migraines|Chronic Rhinitis|Cardiovasc Disease/MI|CHF|Asthma|COPD|ILD|IBS|GERD|Peptic Ulcer Disease|Constipation|IBD|CKD|BPH|Urinary Incontinence|Kidney Stones|Dysmenorrhea|PCOS|Metrorrhagia|Recurrent BV|Recurrent Candidiasis|Pelvic Organ Prolapse|Menopausal Sx|Acne|Seborrheic Dermatitis|Rosacea|Warts|Eczema|Actinic Keratosis|Seborrheic Keratosis|Pseudofolliculitis Barbae"]
 -Goal(s) of treatment - [text size="80"]
 -Pt satisfied with current treatment - [checkbox value="Yes|No"]
 -Current treatment(s) -
  -Nutritional - [checkbox value="N/A|none"][text size="80"]
  -Physical activity - [checkbox value="N/A|none"][text size="80"]
  -Medications - [checkbox value="N/A|none"][text size="80"]
  -Other - [checkbox value="N/A|none"][text size="80"]
 -Previous treatment(s) - [checkbox value="N/A|none"]
[checkbox name="ptx11" value="  -#1 - "][/conditional][conditional field="ptx11" condition="(ptx11).is('  -#1 - ')"][text size="60"], reason discontinued - [checkbox value="intolerable side effects|no improvement"][text memo="other reason" memo_size="small" size="60"]
[/conditional][conditional field="chr1" condition="(chr1).is('-Chronic Condition-')"][checkbox name="ptx12" value="  -#2 - "][/conditional][conditional field="ptx12" condition="(ptx12).is('  -#2 - ')"][text size="60"], reason discontinued - [checkbox value="intolerable side effects|no improvement"][text memo="other reason" memo_size="small" size="60"]
[/conditional][conditional field="chr1" condition="(chr1).is('-Chronic Condition-')"][checkbox name="ptx13" value="  -#3 - "][/conditional][conditional field="ptx13" condition="(ptx13).is('  -#3 - ')"][text size="60"], reason discontinued - [checkbox value="intolerable side effects|no improvement"][text memo="other reason" memo_size="small" size="60"]
[/conditional][conditional field="chr1" condition="(chr1).is('-Chronic Condition-')"] -Surveillance/diagnostic test(s) requested - [checkbox name="surveilltest1" value="N/A|none"][text size="80"]
 -Other specialists comanaging - [checkbox value="N/A|none"][textarea memo="name & specialty & how recently seen" memo_size="small"]

[/conditional][checkbox memo="#2" memo_size="small" name="chr2" value="-Chronic Condition-"][conditional field="chr2" condition="(chr2).is('-Chronic Condition-')"] [text memo="freetext or select one" memo_size="small" size="70"][select value="|Migraines|Chronic Rhinitis|Cardiovasc Disease/MI|CHF|Asthma|COPD|ILD|IBS|GERD|Peptic Ulcer Disease|Constipation|IBD|CKD|BPH|Urinary Incontinence|Kidney Stones|Dysmenorrhea|PCOS|Metrorrhagia|Recurrent BV|Recurrent Candidiasis|Pelvic Organ Prolapse|Menopausal Sx|Acne|Seborrheic Dermatitis|Rosacea|Warts|Eczema|Actinic Keratosis|Seborrheic Keratosis|Pseudofolliculitis Barbae"]
 -Goal(s) of treatment - [text size="80"]
 -Pt satisfied with current treatment - [checkbox value="Yes|No"]
 -Current treatment(s) -
  -Nutritional - [checkbox value="N/A|none"][text size="80"]
  -Physical activity - [checkbox value="N/A|none"][text size="80"]
  -Medications - [checkbox value="N/A|none"][text size="80"]
  -Other - [checkbox value="N/A|none"][text size="80"]
 -Previous treatment(s) - [checkbox value="N/A|none"]
[checkbox name="ptx21" value="  -#1 - "][/conditional][conditional field="ptx21" condition="(ptx21).is('  -#1 - ')"][text size="60"], reason discontinued - [checkbox value="intolerable side effects|no improvement"][text memo="other reason" memo_size="small" size="60"]
[/conditional][conditional field="chr2" condition="(chr2).is('-Chronic Condition-')"][checkbox name="ptx22" value="  -#2 - "][/conditional][conditional field="ptx22" condition="(ptx22).is('  -#2 - ')"][text size="60"], reason discontinued - [checkbox value="intolerable side effects|no improvement"][text memo="other reason" memo_size="small" size="60"]
[/conditional][conditional field="chr2" condition="(chr2).is('-Chronic Condition-')"][checkbox name="ptx23" value="  -#3 - "][/conditional][conditional field="ptx23" condition="(ptx23).is('  -#3 - ')"][text size="60"], reason discontinued - [checkbox value="intolerable side effects|no improvement"][text memo="other reason" memo_size="small" size="60"]
[/conditional][conditional field="chr2" condition="(chr2).is('-Chronic Condition-')"] -Surveillance/diagnostic test(s) requested - [checkbox name="surveilltest2" value="N/A|none"][text size="80"]
 -Other specialists comanaging - [checkbox value="N/A|none"][textarea memo="name & specialty & how recently seen" memo_size="small"]

[/conditional][checkbox memo="#3" memo_size="small" name="chr3" value="-Chronic Condition-"][conditional field="chr3" condition="(chr3).is('-Chronic Condition-')"] [text memo="freetext or select one" memo_size="small" size="70"][select value="|Migraines|Chronic Rhinitis|Cardiovasc Disease/MI|CHF|Asthma|COPD|ILD|IBS|GERD|Peptic Ulcer Disease|Constipation|IBD|CKD|BPH|Urinary Incontinence|Kidney Stones|Dysmenorrhea|PCOS|Metrorrhagia|Recurrent BV|Recurrent Candidiasis|Pelvic Organ Prolapse|Menopausal Sx|Acne|Seborrheic Dermatitis|Rosacea|Warts|Eczema|Actinic Keratosis|Seborrheic Keratosis|Pseudofolliculitis Barbae"]
 -Goal(s) of treatment - [text size="80"]
 -Pt satisfied with current treatment - [checkbox value="Yes|No"]
 -Current treatment(s) -
  -Nutritional - [checkbox value="N/A|none"][text size="80"]
  -Physical activity - [checkbox value="N/A|none"][text size="80"]
  -Medications - [checkbox value="N/A|none"][text size="80"]
  -Other - [checkbox value="N/A|none"][text size="80"]
 -Previous treatment(s) - [checkbox value="N/A|none"]
[checkbox name="ptx31" value="  -#1 - "][/conditional][conditional field="ptx31" condition="(ptx31).is('  -#1 - ')"][text size="60"], reason discontinued - [checkbox value="intolerable side effects|no improvement"][text memo="other reason" memo_size="small" size="60"]
[/conditional][conditional field="chr3" condition="(chr3).is('-Chronic Condition-')"][checkbox name="ptx32" value="  -#2 - "][/conditional][conditional field="ptx32" condition="(ptx32).is('  -#2 - ')"][text size="60"], reason discontinued - [checkbox value="intolerable side effects|no improvement"][text memo="other reason" memo_size="small" size="60"]
[/conditional][conditional field="chr3" condition="(chr3).is('-Chronic Condition-')"][checkbox name="ptx33" value="  -#3 - "][/conditional][conditional field="ptx33" condition="(ptx33).is('  -#3 - ')"][text size="60"], reason discontinued - [checkbox value="intolerable side effects|no improvement"][text memo="other reason" memo_size="small" size="60"]
[/conditional][conditional field="chr3" condition="(chr3).is('-Chronic Condition-')"] -Surveillance/diagnostic test(s) requested - [checkbox name="surveilltest3" value="N/A|none"][text size="80"]
 -Other specialists comanaging - [checkbox value="N/A|none"][textarea memo="name & specialty & how recently seen" memo_size="small"]

[/conditional][checkbox memo="#4" memo_size="small" name="chr4" value="-Chronic Condition-"][conditional field="chr4" condition="(chr4).is('-Chronic Condition-')"] [text memo="freetext or select one" memo_size="small" size="70"][select value="|Migraines|Chronic Rhinitis|Cardiovasc Disease/MI|CHF|Asthma|COPD|ILD|IBS|GERD|Peptic Ulcer Disease|Constipation|IBD|CKD|BPH|Urinary Incontinence|Kidney Stones|Dysmenorrhea|PCOS|Metrorrhagia|Recurrent BV|Recurrent Candidiasis|Pelvic Organ Prolapse|Menopausal Sx|Acne|Seborrheic Dermatitis|Rosacea|Warts|Eczema|Actinic Keratosis|Seborrheic Keratosis|Pseudofolliculitis Barbae"]
 -Goal(s) of treatment - [text size="80"]
 -Pt satisfied with current treatment - [checkbox value="Yes|No"]
 -Current treatment(s) -
  -Nutritional - [checkbox value="N/A|none"][text size="80"]
  -Physical activity - [checkbox value="N/A|none"][text size="80"]
  -Medications - [checkbox value="N/A|none"][text size="80"]
  -Other - [checkbox value="N/A|none"][text size="80"]
 -Previous treatment(s) - [checkbox value="N/A|none"]
[checkbox name="ptx41" value="  -#1 - "][/conditional][conditional field="ptx41" condition="(ptx41).is('  -#1 - ')"][text size="60"], reason discontinued - [checkbox value="intolerable side effects|no improvement"][text memo="other reason" memo_size="small" size="60"]
[/conditional][conditional field="chr4" condition="(chr4).is('-Chronic Condition-')"][checkbox name="ptx42" value="  -#2 - "][/conditional][conditional field="ptx42" condition="(ptx42).is('  -#2 - ')"][text size="60"], reason discontinued - [checkbox value="intolerable side effects|no improvement"][text memo="other reason" memo_size="small" size="60"]
[/conditional][conditional field="chr4" condition="(chr4).is('-Chronic Condition-')"][checkbox name="ptx43" value="  -#3 - "][/conditional][conditional field="ptx43" condition="(ptx43).is('  -#3 - ')"][text size="60"], reason discontinued - [checkbox value="intolerable side effects|no improvement"][text memo="other reason" memo_size="small" size="60"]
[/conditional][conditional field="chr4" condition="(chr4).is('-Chronic Condition-')"] -Surveillance/diagnostic test(s) requested - [checkbox name="surveilltest4" value="N/A|none"][text size="80"]
 -Other specialists comanaging - [checkbox value="N/A|none"][textarea memo="name & specialty & how recently seen" memo_size="small"]

[/conditional][checkbox memo="#5" memo_size="small" name="chr5" value="-Chronic Condition-"][conditional field="chr5" condition="(chr5).is('-Chronic Condition-')"] [text memo="freetext or select one" memo_size="small" size="70"][select value="|Migraines|Chronic Rhinitis|Cardiovasc Disease/MI|CHF|Asthma|COPD|ILD|IBS|GERD|Peptic Ulcer Disease|Constipation|IBD|CKD|BPH|Urinary Incontinence|Kidney Stones|Dysmenorrhea|PCOS|Metrorrhagia|Recurrent BV|Recurrent Candidiasis|Pelvic Organ Prolapse|Menopausal Sx|Acne|Seborrheic Dermatitis|Rosacea|Warts|Eczema|Actinic Keratosis|Seborrheic Keratosis|Pseudofolliculitis Barbae"]
 -Goal(s) of treatment - [text size="80"]
 -Pt satisfied with current treatment - [checkbox value="Yes|No"]
 -Current treatment(s) -
  -Nutritional - [checkbox value="N/A|none"][text size="80"]
  -Physical activity - [checkbox value="N/A|none"][text size="80"]
  -Medications - [checkbox value="N/A|none"][text size="80"]
  -Other - [checkbox value="N/A|none"][text size="80"]
 -Previous treatment(s) - [checkbox value="N/A|none"]
[checkbox name="ptx51" value="  -#1 - "][/conditional][conditional field="ptx51" condition="(ptx51).is('  -#1 - ')"][text size="60"], reason discontinued - [checkbox value="intolerable side effects|no improvement"][text memo="other reason" memo_size="small" size="60"]
[/conditional][conditional field="chr5" condition="(chr5).is('-Chronic Condition-')"][checkbox name="ptx52" value="  -#2 - "][/conditional][conditional field="ptx52" condition="(ptx52).is('  -#2 - ')"][text size="60"], reason discontinued - [checkbox value="intolerable side effects|no improvement"][text memo="other reason" memo_size="small" size="60"]
[/conditional][conditional field="chr5" condition="(chr5).is('-Chronic Condition-')"][checkbox name="ptx53" value="  -#3 - "][/conditional][conditional field="ptx53" condition="(ptx53).is('  -#3 - ')"][text size="60"], reason discontinued - [checkbox value="intolerable side effects|no improvement"][text memo="other reason" memo_size="small" size="60"]
[/conditional][conditional field="chr5" condition="(chr5).is('-Chronic Condition-')"] -Surveillance/diagnostic test(s) requested - [checkbox name="surveilltest5" value="N/A|none"][text size="80"]
 -Other specialists comanaging - [checkbox value="N/A|none"][textarea memo="name & specialty & how recently seen" memo_size="small"]

[/conditional]-Lifestyle risk factor modification/optimization -
 -If smoking/chewing/vaping, patient indicates willingness to discuss quitting? [checkbox value="N/A|Yes|No"]
 -If consuming alcohol in significant amts daily, patient indicates willingness to discuss cutting back? [checkbox value="N/A|Yes|No"]
 -If overweight/obese, patient indicates willingness to discuss? [checkbox value="N/A|Yes|No"]

-Questions/concerns of patient about these above conditions: [checkbox value="none"][textarea rows="4"]