Subjective/History Elements
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approximately 192 views since someone stopped to smell the roses.
[checkbox name="sportsphys" value="Pre-participation Sports Evaluation"][conditional field="sportsphys" condition="(sportsphys).is('Pre-participation Sports Evaluation')"]
-Sports that patient desires to participate: [text size="80"][checklist value="Anyone in the athlete’s family died suddenly before the age of 50 years?|Athlete ever passed out during exercise or stopped exercising because of dizziness or chest pain?|Athlete have asthma (wheezing), hay fever, other allergies, or carry an EPI pen?|Athlete allergic to any medications or bee stings?|Athlete ever broken a bone, had to wear a cast, or had an injury to any joint?|Athlete ever had a head injury or concussion?|Athlete ever had a hit or blow to the head that caused confusion, memory problems, or prolonged headache?|Athlete ever suffered a heat‐related illness (heat stroke)?|Athlete have a chronic illness or see a physician regularly for any particular problem?|Athlete take any prescribed medicine, herbs or nutritional supplements?|Athlete have only one of any paired organ (eyes, kidneys, testicles, ovaries, etc.)?|Athlete ever had prior limitation from sports participation?|Athlete had any episodes of shortness of breath, palpitations, history of rheumatic fever or tiring easily?|Athlete ever been diagnosed with a heart murmur or heart condition or hypertension?|Hx of young people in the athlete’s family who have had heart disease: ie. cardiomyopathy, abnormal heart rhythms, long QT or Marfan's syndrome?|Athlete ever been hospitalized overnight or had surgery?|Athlete lose weight regularly to meet the requirements for your sport?|Athlete have anything he or she wants to discuss with the physician?|Athlete cough, wheeze, or have trouble breathing during or after activity?|Athlete unhappy with his or her weight?"]
[checkbox memo="display/hide references" name="ppefootnotes" value=""]
[/conditional][conditional field="ppefootnotes" condition="(ppefootnotes).is('')"][link memo="Mirabelli MH, Devine MJ, Singh J, Mendoza M. The Preparticipation Sports
Evaluation. Am Fam Physician. 2015 Sep 1;92(5):371-6." url="https://www.ncbi.nlm.nih.gov/pubmed/26371570"]
[/conditional][checkbox name="wellvisit" value="Well Visit"][conditional field="wellvisit" condition="(wellvisit).is('Well Visit')"] for [select name="Q1" value="|1 week|2 week|1 month|2 month|4 month|6 month|9 month|12 month|15 month|18 month|2 year|3 year|4 year|5 year|6-10 year|11-14 year|15-18 year"] [select name="Q2" value="|female|male"] patient

[/conditional][conditional field="Q1" condition="(Q1).is('1 week')||(Q1).is('2 week')||(Q1).is('1 month')"]SUBJECTIVE/HISTORY:
Parent/caregiver report
[checkbox value="-Completed Ages and Stages Questionnaire (ASQ).
"][checkbox value="-Has done well since hospital discharge.
"][checkbox value="-No growth concerns.
"][checkbox value="-Alert to sights and sounds.
"][checkbox value="-No problems with urine or stool.
"][checkbox value="-Quiets with comforting.
"][checkbox value="-Sleeps on back.
"][checkbox value="-Newborn screen pending.
"][checkbox value="-Newborn screen negative
"][checkbox value="-No tobacco exposure.
"][/conditional][conditional field="Q1" condition="(Q1).is('2 month')"]SUBJECTIVE/HISTORY:
Parent/caregiver report
[checkbox value="-Completed Ages and Stages Questionnaire (ASQ).
"][checkbox value="-Has done well over the past month.
"][checkbox value="-No growth concerns.
"][checkbox value="-No concerns regarding hearing.
"][checkbox value="-No problems with urine or stool.
"][checkbox value="-Sleeps on back.
"][checkbox value="-Usual sleep pattern.
"][checkbox value="-No tobacco exposure.
"][/conditional][conditional field="Q1" condition="(Q1).is('4 month')"]SUBJECTIVE/HISTORY:
Parent/caregiver report
[checkbox value="-Completed Ages and Stages Questionnaire (ASQ).
"][checkbox value="-Has done well over the past two months.
"][checkbox value="-No growth concerns.
"][checkbox value="-No concerns regarding hearing.
"][checkbox value="-No problems with urine or stool.
"][checkbox value="-Sleeps on back.
"][checkbox value="-Usual sleep pattern.
"][checkbox value="-No tobacco exposure.
"][/conditional][conditional field="Q1" condition="(Q1).is('6 month')"]SUBJECTIVE/HISTORY:
Parent/caregiver report
[checkbox value="-Completed Ages and Stages Questionnaire (ASQ).
"][checkbox value="-Has done well over the past two months.
"][checkbox value="-No growth concerns.
"][checkbox value="-No concerns regarding hearing.
"][checkbox value="-No problems with urine or stool.
"][checkbox value="-No significant sleep concerns.
"][checkbox value="-No previous immunization reactions.
"][checkbox value="-No tobacco exposure.
"][/conditional][conditional field="Q1" condition="(Q1).is('9 month')"]SUBJECTIVE/HISTORY:
Parent/caregiver report
[checkbox value="-Completed Ages and Stages Questionnaire (ASQ).
"][checkbox value="-Has done well over the past few months.
"][checkbox value="-No growth concerns.
"][checkbox value="-Speech includes repetitive sounds and conversational babble.
"][checkbox value="-No concerns regarding hearing.
"][checkbox value="-No problems with urine or stool.
"][checkbox value="-Some night awakening and stranger anxiety.
"][checkbox value="-No tobacco exposure.
"][/conditional][conditional field="Q1" condition="(Q1).is('12 month')"]SUBJECTIVE/HISTORY:
Parent/caregiver report
[checkbox value="-Completed Ages and Stages Questionnaire (ASQ).
"][checkbox value="-Has done well over the past few months.
"][checkbox value="-No growth concerns.
"][checkbox value="-No concerns regarding hearing.
"][checkbox value="-No problems with urine or stool.
"][checkbox value="-No significant sleep issues.
"][checkbox value="-No tobacco exposure.
"][/conditional][conditional field="Q1" condition="(Q1).is('15 month')||(Q1).is('18 month')"]SUBJECTIVE/HISTORY:
Parent/caregiver report
[checkbox value="-Completed Ages and Stages Questionnaire (ASQ).
"][checkbox value="-Completed M-CHAT-R (Modified Checklist for Autism in Toddlers, screening at 16-30mo of age).
"][checkbox value="-Has done well over the past few months.
"][checkbox value="-Nutrition includes table foods along with whole milk and occasional juice.
"][checkbox value="-No growth concerns.
"][checkbox value="-No concerns regarding hearing.
"][checkbox value="-No problems with urine or stool.
"][checkbox value="-No significant sleep concerns.
"][checkbox value="-No tobacco exposure.
"][/conditional][conditional field="Q1" condition="(Q1).is('2 year')"]SUBJECTIVE/HISTORY:
Parent/caregiver report
[checkbox value="-Completed Ages and Stages Questionnaire (ASQ).
"][checkbox value="-Completed M-CHAT-R (Modified Checklist for Autism in Toddlers, screening at 16-30mo of age).
"][checkbox value="-Has been generally healthy over the past few months.
"][checkbox value="-Nutrition includes milk and a variety of foods.
"][checkbox value="-Use of Vitamins/Fluoride.
"][checkbox value="-No growth concerns.
"][checkbox value="-No concerns regarding hearing.
"][checkbox value="-No significant sleep concerns.
"][checkbox value="-No significant reaction to previous immunizations.
"][checkbox value="-No lead risk/Not exposed to housing 1950 or older.
"][checkbox value="-No TB risk/exposure to TB is unlikely.
"][checkbox value="-Neither parent with cholesterol greater than 300.
"][checkbox value="-No tobacco exposure.
"][/conditional][conditional field="Q1" condition="(Q1).is('3 year')"]SUBJECTIVE/HISTORY:
Parent/caregiver report
[checkbox value="-Completed Ages and Stages Questionnaire (ASQ).
"][checkbox value="-Has been generally healthy over the past few months.
"][checkbox value="-Nutrition includes milk and a variety of foods.
"][checkbox value="-Use of Vitamins/Fluoride.
"][checkbox value="-No growth concerns.
"][checkbox value="-No significant sleep issues.
"][checkbox value="-No significant reaction to previous immunizations.
"][checkbox value="-No lead risk/Not exposed to housing 1950 or older.
"][checkbox value="-No TB risk/exposure to TB is unlikely.
"][checkbox value="-Neither parent with cholesterol greater than 300.
"][checkbox value="-No tobacco exposure.
"][/conditional][conditional field="Q1" condition="(Q1).is('4 year')"]SUBJECTIVE/HISTORY:
Parent/caregiver/child report
[checkbox value="-Has been generally healthy over the past year.
"][checkbox value="-Nutrition includes milk and a variety of foods.
"][checkbox value="-No growth concerns.
"][checkbox value="-No tobacco exposure.
"][/conditional][conditional field="Q1" condition="(Q1).is('5 year')"]SUBJECTIVE/HISTORY:
Parent/caregiver/child report
[checkbox value="-Has been generally healthy over the past year.
"][checkbox value="-Nutrition includes milk and a variety of foods.
"][checkbox value="-No growth concerns.
"][checkbox value="-No concerns regarding school readiness.
"][checkbox value="-No previous reaction to immunizations.
"][checkbox value="-No lead exposure risk.
"][checkbox value="-No tobacco exposure.
"][/conditional][conditional field="Q1" condition="(Q1).is('6-10 year')"]SUBJECTIVE/HISTORY:
Parent/caregiver/child report
[checkbox value="-Has been generally healthy over the past year.
"][checkbox value="-Nutrition includes a variety of foods and adequate balance.
"][checkbox value="-No growth concerns.
"][checkbox value="-Exercise is regular.
"][checkbox value="-No height/weight concerns.
"][checkbox value="-No school performance or social interaction concerns.
"][checkbox value="-No problems with urine or stool.
"][checkbox value="-Denies smoking/vaping.
"][/conditional][conditional field="Q1" condition="(Q1).is('11-14 year')"]SUBJECTIVE/HISTORY:
Parent/caregiver/child report
[checkbox value="-Has been generally healthy over the past year.
"][checkbox value="-Nutrition includes a variety of foods and adequate balance.
"][checkbox value="-No growth concerns.
"][checkbox value="-Exercise is regular.
"][checkbox value="-No height/weight concerns.
"][checkbox value="-No school performance or social interaction concerns.
"][checkbox value="-No problems with urine or stool.
"][checkbox value="-Denies sexual activity, smoking/vaping, alcohol or other drug use.
"][/conditional][conditional field="Q1" condition="(Q1).is('15-18 year')"]SUBJECTIVE/HISTORY:
Parent/caregiver/child report
[checkbox value="-Has been generally healthy over the past year.
"][checkbox value="-Nutrition includes a variety of foods and adequate balance.
"][checkbox value="-No growth concerns.
"][checkbox value="-Exercise is regular.
"][checkbox value="-No height/weight concerns.
"][checkbox value="-Has education and work plans.
"][checkbox value="-Denies depression/anhedonia.
"][checkbox value="-No problems with urine or stool.
"][checkbox value="-Denies sexual activity, smoking/vaping, alcohol or other drug use.
"]
[/conditional]Parent/caregiver/patient concerns expressed or discovered: [checkbox value="none"][textarea memo="include parent concerns, explanation of any positive/abnormal answers/ROS items above" memo_size="small" rows="8"]

[conditional field="Q1" condition="(Q1).is('1 week')||(Q1).is('2 week')||(Q1).is('1 month')||(Q1).is('2 month')||(Q1).is('4 month')||(Q1).is('6 month')||(Q1).is('9 month')||(Q1).is('12 month')"]NUTRITION
[comment memo="*" memo_color="blue"][select value="appropriate amount|not applicable|NOT ON TRACK"] <-- Breast Feeding [comment memo="
0-2 months: on demand, 10-12 feedings daily
2-4 months: on demand, 10-12 feedings daily
4-6 months: 8-10 feedings daily
6-8 months: 6-8 feedings daily
8-10 months: 4-6 feedings daily
over 10 months: may wean" memo_size="small"]
[comment memo="*" memo_color="blue"][select value="not applicable|appropriate amount|NOT ON TRACK"] <-- Iron-Fortified Formula [comment memo="
0-2 months: 6-8 feedings, 16-26 ounces daily.
2-4 months: 4-6 feedings, 26-32 ounces daily
4-6 months: 26-40 ounces daily
6-8 months: 24-32 ounces daily
8-10 months: 20-24 ounces daily
10-12 months: 16-24 ounces daily. offer dairy products such as plain yogurt or mild cheese.
over 12 months: 2-3 cups 2% or whole milk. NO MORE BOTTLES" memo_size="small"]
[comment memo="*" memo_color="blue"][select value="appropriate amount|NOT ON TRACK"] <-- Cereal [comment memo="
0-4 months: none
4-6 months: 1-2 tablespoons twice daily, thin with breast milk or formula, start with rice cereal.
6-8 months: ¼ to ½ cup baby cereal mixed with breast milk or formula
8-10 months: ¼ to ½ cup cereals, toast, mashed potato, rice or noodles
10-12 months: thicker cereal, increase serving size according to appetite
over 12 months: 4 servings per day" memo_size="small"]
[comment memo="*" memo_color="blue"][select value="appropriate amount|NOT ON TRACK"] <-- Vegetables [comment memo="
0-6 months: none
6-8 months: strained vegetables 3-4 Tbsp. twice daily. start with green, then yellow type.
8-10 months: may advance to junior strained vegetables or tender vegetables from the table.
10-12 months: increase serving size according to appetite.
over 12 months: 2-3 small servings daily. Offer a variety." memo_size="small"]
[comment memo="*" memo_color="blue"][select value="appropriate amount|NOT ON TRACK"] <-- Juices/Fruits [comment memo="
0-6 months: none
6-8 months: unsweetened juice from cup, vitamin C fortified, no more than 1/2 cup daily. begin with apple juice. start with baby juice or dilute adult juice (half juice, half water).
8-10 months: limit to 1/2 cup unsweetened juice daily. begin strained fruits 3-4 tbsp. twice daily.
10-12 months: continue to limit to 1/2 cup unsweetened juice daily. 3-4 Tbsp. strained fruit per day. Soft pieces of ripe, raw, peeled fruit.
over 12 months: 2-3 small servings of fruit or juice daily. Offer a variety. Limit juice to 4 oz. daily." memo_size="small"]
[comment memo="*" memo_color="blue"][select value="appropriate amount|NOT ON TRACK"] <-- Meats/Eggs/Protein [comment memo="
0-8 months: none
8-10 months: strained meat, baby egg yolk or hard cooked egg yolk, 1-2 Tbsp. daily. well-cooked beans or peas.
10-12 months: 1-2 Tbsp. finely chopped meats once or twice daily.
over 12 months: 2 one ounce servings of protein foods such as meat, eggs, dried beans, peas." memo_size="small"]
[comment memo="*" memo_color="blue"][select value="none|occasional|REGULAR/DAILY CONSUMPTION"] <-- Soda Pop [comment memo="
Preferably none!" memo_size="small"]

[/conditional][conditional field="Q1" condition="(Q1).is('1 week')||(Q1).is('2 week')"]DEVELOPMENT
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Eats well
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Can suck, swallow and breath easy

[/conditional][conditional field="Q1" condition="(Q1).is('1 month')"]DEVELOPMENT
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Fixes on faces
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Lifts chin off surface

[/conditional][conditional field="Q1" condition="(Q1).is('2 month')"]DEVELOPMENT
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Starting to smile
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Coos or making gurgling sounds
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Watches things as they move
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Moves all arms and legs equally

[/conditional][conditional field="Q1" condition="(Q1).is('4 month')"]DEVELOPMENT
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Smiles on their own or in response to someone
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Holds head steady when held upright
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Coos or babbles
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Elicits attention and likes to play
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Reaches for objects that they want
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Rolls from front onto back
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Uses arms to push chest off surface when on tummy
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Brings things to mouth

[/conditional][conditional field="Q1" condition="(Q1).is('6 month')"]DEVELOPMENT
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Rolls from front onto back and back to front
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Enjoys interacting with people, especially parents
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Sits briefly leaning forward
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Curious and looks at nearby objects, often reaching for them
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Passes toys from one hand to another and to their mouth

[/conditional][conditional field="Q1" condition="(Q1).is('9 month')"]DEVELOPMENT
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Plays peekaboo
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Has stranger anxiety or seeks parents for comfort
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Uses thumb and pointer to pick up small objects
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Bears weight on legs with support
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Moves to get objects that are too far to reach
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Makes a lot of different sounds (like 'dadadada' or 'mamamama')
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Looks at where you point
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Transfers objects between hands

[/conditional][conditional field="Q1" condition="(Q1).is('12 month')"]DEVELOPMENT
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Uses 'Mama' or 'Dada' for specific parents
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Takes first independent steps or stands with support
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Uses a gesture (like waving 'bye' or shaking head for 'no')
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Bangs objects together
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Walks holding onto furniture
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Cries when caregivers leave
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Points to objects

[/conditional][conditional field="Q1" condition="(Q1).is('15 month')"]DEVELOPMENT
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Walks unassisted
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Understands and follows simple commands (get the ball)
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Drinks from cup with very little spilling
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Listens to a story
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Brings and shows toys
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Regularly uses 3 words

[/conditional][conditional field="Q1" condition="(Q1).is('18 month')"]DEVELOPMENT
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Points to body parts
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Helps with simple tasks
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Plays pretend or copies activities (such as feeding a doll)
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Points to show something of interest
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Starting to run
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Using spoon (utensils) to eat
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Uses 6 or more words regularly

[/conditional][conditional field="Q1" condition="(Q1).is('2 year')"]DEVELOPMENT
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Plays pretend and copies others
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Jumps up and down in place
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Points to 6 body parts
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Sorts colors and shapes with some assistance
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Has over 50 words
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Plays interactively with other children

[/conditional][conditional field="Q1" condition="(Q1).is('3 year')"]DEVELOPMENT
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Plays make believe
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Toilet trained during the day
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Copies circle
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Speak in multiple work sentences
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Most words are understandable

[/conditional][conditional field="Q1" condition="(Q1).is('4 year')"]DEVELOPMENT
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Dresses without help
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Is creative during play
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Strangers can understand almost everything the patient says
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Name 4 colors
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Hops on one foot
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Copies a cross
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Knows their name and age

[/conditional][conditional field="Q1" condition="(Q1).is('5 year')"]DEVELOPMENT
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Speech is clear and understandable
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Counts to 10
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Draws a person with at least 6 body parts
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Copies at triangle or square
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Balance on one foot for 10 seconds

[/conditional][conditional field="Q1" condition="(Q1).is('6-10 year')"]DEVELOPMENT
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Does chores at home when asked
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Gets along with family and friends
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Engages in after-school activities
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Reading and doing math at grade level
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Eating healthy food and snacks
[comment memo="*" memo_color="blue"][select value="Yes|Not Yet"] <-- Has positive self-image

[/conditional][conditional field="Q1" condition="(Q1).is('11-14 year')||(Q1).is('15-18 year')"]HEADSSS QUESTIONS
-Home: [checkbox value="discussed|no concerns|the following concerns-"] [text size="80"]
-Education: [checkbox value="discussed|no concerns|the following concerns-"] [text size="80"]
-Activities: [checkbox value="discussed|no concerns|the following concerns-"] [text size="80"]
-Drugs: [checkbox value="discussed|no concerns|the following concerns-"] [text size="80"]
-Sexuality: [checkbox value="discussed|no concerns|the following concerns-"] [text size="80"]
-Suicide: [checkbox value="discussed|no concerns/SI|the following concerns-"] [text size="80"]
-Safety: [checkbox value="discussed|no concerns|the following concerns-"] [text size="80"]

[/conditional][conditional field="Q1" condition="(Q1).is('1 week')||(Q1).is('2 month')||(Q1).is('4 month')||(Q1).is('6 month')||(Q1).is('9 month')||(Q1).is('12 month')||(Q1).is('15 month')||(Q1).is('18 month')"]REVIEW OF SYSTEMS
[checklist value="fever|nasal congestion|nasal discharge|pulling at the ears|cough|wheezing|vomiting|diarrhea|abdominal pain|decrease in appetite|rash|poor weight gain|hearing concerns|vision problems|eye discharge|difficulty breathing|snoring|change in bowel habits|excessive thirst|acting fussy|wheezing worse with URI|cough with exercise|nighttime cough|daytime cough"]

[/conditional][conditional field="Q1" condition="(Q1).is('2 year')||(Q1).is('3 year')"]REVIEW OF SYSTEMS
[checklist value="fever|headache|nasal congestion|nasal discharge|earache|pulling on the ears|eye discharge|sore throat|cough|wheezing|vomiting|diarrhea|abdominal pain|decrease in appetite|rash|vision problems|hearing concerns|snoring|chest pain|difficulty breathing|urinary habit change|change in bowel habits|excessive thirst|limb pain|syncope/fainting|wheezing worse with a cold|cough with exercise|nighttime cough|daytime cough|palpitations|emotional lability|tics|recent unintentional weight loss|trouble falling asleep|sleep disturbance"]

[/conditional][conditional field="Q1" condition="(Q1).is('4 year')||(Q1).is('5 year')||(Q1).is('6-10 year')"]REVIEW OF SYSTEMS
[checklist value="fever|headache|nasal congestion|nasal discharge|earache|pulling on the ears|eye discharge|sore throat|cough|wheezing|vomiting|diarrhea|abdominal pain|decreased appetite|rash|weight change|sleep disturbance|chest pain|vision problems|hearing concerns|difficulty breathing|syncope/fainting|snoring|change in bowel habits|limb pain|excessive thirst|urinary habits change|wheezing worse with a cold|cough with exercise|nighttime cough|daytime cough|palpitations|emotional lability|tics|recent unintentional weight loss|trouble falling asleep|feels overweight|feels underweight|feels tired|chest pain with exertion|dyspnea with exertion|syncope with exercise|dizziness|limb numbness"]

[/conditional][conditional field="Q1" condition="(Q1).is('11-14 year')||(Q1).is('15-18 year')"]REVIEW OF SYSTEMS
[checklist value="fever|headache|nasal congestion|nasal discharge|earache|pulling on the ears|eye discharge|sore throat|cough|wheezing|vomiting|diarrhea|abdominal pain|decreased appetite|rash|weight change|sleep disturbance|chest pain|difficulty breathing|syncope/fainting|snoring|change in bowel habits|limb pain|excessive thirst|urinary habits change|wheezing worse with a cold|cough with exercise|nighttime cough|daytime cough|palpitations|emotional lability|tics|recent unintentional weight loss|trouble falling asleep|feels overweight|feels underweight|feels tired|chest pain with exertion|dyspnea with exertion|syncope with exercise|dizziness|limb numbness"]

[/conditional]
Parent/caregiver/patient concerns expressed or discovered: include parent concerns, explanation of any positive/abnormal answers/ROS items above

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