Normal Pre-Anesthesia Medical Examination History

History of Present Illness:  [text size=96 default="Reports being in normal state of health.  Denies current fever, chills, headache, cough, nausea, vomiting, diarrhea.  "]

Allergy History:  [text size=96 default="No history of drug allergies or allergic reactions.  "]
Alcohol Use:  [text size=96 default="No chronic alcohol use.  "]
Tobacco Use:  [text size=96 default="No significant history of smoking or vaping.  "]
Marijuana Use:  [text size=96 default="No significant history of smoking marijuana.  "]
Other Drugs of Abuse:  [text size=96 default="No significant history of oral, injected, or inhaled drugs of abuse.  "]
Supplements and Herbal Medications:  [text size=96 default="No use of vitamin supplements.  Does not take Echinacea, Ephedra, Ginkgo (used for memory loss), Ginseng, Hawthorn (used for cardiac symptoms, Melatonin (used for insomnia), Saw Palmetto (used for prostate symptoms), St. John’s Wort (used for mental symptoms), or Valerian Root (used for insomnia).  "]

Ophthalmologic:  [text size=96 default="Does not have glaucoma.  Does not use oral or topical medications for eye problem.  "]
Dental:  [text size=96 default="Does not wear dentures.  "]

Cardiac Disease:  [text size=96 default="No history of myocardial infarction, decreased functional ability, or newly detected murmur.  Not taking medication for hypertension, hyperlipidemia, coronary artery disease, or congestive heart failure.  "]

Anesthesia:  [text size=96 default="No complications with anesthesia in past surgeries or procedures.  "] 
Asthma:  [text size=96 default="No history of asthma.  No inhaled or oral medications for asthma.  "]
Chronic Obstructive Pulmonary Disease:  [text size=96 default="No history of COPD.  No inhaled or oral medications for COPD."]
Sleep apnea:  [text size=96 default="No history of obstructive sleep apnea.  Sleep apnea is not suspected.  The patient does not use a CPAP or BiPAP device.  "]

Bleeding:  [text size=96 default="No unusual bleeding or bruising.  No history of bleeding disorders.  No history of transfusions.  "]
Anticoagulation:  [text size=96 default="Not currently taking aspirin, clopidogrel, prasugrel, coumadin, or direct oral anticoagulants"]

Chronic Infection:  [text size=96 default="No history of HIV or infectious hepatitis.  "]

Diabetes Mellitus:  [text size=96 default="No history of diabetes.  Not taking insulin or injected hypoglycemic or oral hypoglycemic medications.  "]
Thyroid:  [text size=96 default="No history of hypothyroidism or hyperthyroidism.  Not taking levothyroxine.  "]
Corticosteroids:  [text size=96 default="No history of chronic oral corticosteroid use.  "]

Planning:  [text size=96 default="No living will or advance directive.  "]
History of Present Illness:

Allergy History:
Alcohol Use:
Tobacco Use:
Marijuana Use:
Other Drugs of Abuse:
Supplements and Herbal Medications:


Cardiac Disease:

Chronic Obstructive Pulmonary Disease:
Sleep apnea:


Chronic Infection:

Diabetes Mellitus:


Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0, 21 form elements, 42 boilerplate words, 21 text boxes, 21 total clicks
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