Subjective/History Elements
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[comment memo="Miscellaneous Non-acute Patient Requests"]
[text size="3"]yo [select value="M|F"] requesting-
[checkbox memo="Referral Request" name="Referral" value=""][conditional field="Referral" condition="(Referral).is('')"]
Referral Request
-Referral to [text size="50"][comment memo="specialty"]
-Patient has previously seen this specialty: [select name="New" value="Yes|No"]
-Patient has previously been seen by a specialist here in the local area: [select name="COC1" value="No|Yes"][/conditional][conditional field="COC1" condition="(COC1).is('Yes')"]
-Patient desires to continue being seen by this same provider: [select name="COC2" value="No|Yes"][/conditional][conditional field="COC2" condition="(COC2).is('Yes')"]
-Provider Name, Practice Name, FAX, Address: [textarea][/conditional][conditional field="Referral" condition="(Referral).is('')"]
-Diagnosis for which patient is requesting care by this specialist: [text size="30"]
-Treatments and evaluation that patient is currently receiving or seeking from this specialty: [textarea][/conditional][conditional field="New" condition="(New).is('No')"]
-Symptoms or diagnosis: [text size="50"]
-Onset: [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 [select value="1|2|3|4|5|6|7|8|9|10"]/10 in severity.
-Describes the character/quality as [checkbox value="sharp|dull|burning|tingling|N/A"][text size="30"].[comment memo="Other comments on character/quality"]
-Above symptom(s) [select value="do not travel/radiate|travel/radiate to"] [text size="25"].
-[select value="Denies any associated symptoms|Reports these associated symptoms that started around the same time-"] [text size="25"]
-Symptoms are improved with [text size ="50"]
-Symptoms are worsened by [text size="50"][/conditional][conditional field="Referral" condition="(Referral).is('')"]
[comment memo="Additional comments:"][textarea][/conditional]
[checkbox memo="Medication Refill Request" name="Meds" value=""][conditional field="Meds" condition="(Meds).is('')"]
Medication Refill Request
[checkbox memo="1st condition" name="1" value=""][/conditional][conditional field="1" condition="(1).is('')"]#1:
-Condition/diagnosis that is being treated with medication: [text size="40"]
-Name(s) of medication(s): [textarea]
-Effect of medication(s): [checkbox value="working well|no side effects of concern to patient|NOT working well|UNDESIRABLE side effects"]. [text size="60"][comment memo="add'l comments"][/conditional]
[conditional field="Meds" condition="(Meds).is('')"][checkbox memo="2nd condition" name="2" value=""][/conditional][conditional field="2" condition="(2).is('')"]#2:
-Condition/diagnosis that is being treated with medication: [text size="40"]
-Name(s) of medication(s): [textarea]
-Effect of medication(s): Pt reports [checkbox value="working well|no side effects of concern to patient|NOT working well|UNDESIRABLE side effects"]. [text size="60"][comment memo="add'l comments"][/conditional]
[conditional field="Meds" condition="(Meds).is('')"][checkbox memo="3rd condition" name="3" value=""][/conditional][conditional field="3" condition="(3).is('')"]#3:
-Condition/diagnosis that is being treated with medication: [text size="40"]
-Name(s) of medication(s): [textarea]
-Effect of medication(s): Pt reports [checkbox value="working well|no side effects of concern to patient|NOT working well|UNDESIRABLE side effects"]. [text size="60"][comment memo="add'l comments"][/conditional]
[conditional field="Meds" condition="(Meds).is('')"][checkbox memo="4th condition" name="4" value=""][/conditional][conditional field="4" condition="(4).is('')"]#4:
-Condition/diagnosis that is being treated with medication: [text size="40"]
-Name(s) of medication(s): [textarea]
-Effect of medication(s): Pt reports [checkbox value="working well|no side effects of concern to patient|NOT working well|UNDESIRABLE side effects"]. [text size="60"][comment memo="add'l comments"][/conditional]
[conditional field="Meds" condition="(Meds).is('')"][checkbox memo="5th condition" name="5" value=""][/conditional][conditional field="5" condition="(5).is('')"]#5:
-Condition/diagnosis that is being treated with medication: [text size="40"]
-Name(s) of medication(s): [textarea]
-Effect of medication(s): Pt reports [checkbox value="working well|no side effects of concern to patient|NOT working well|UNDESIRABLE side effects"]. [text size="60"][comment memo="add'l comments"][/conditional]
[checkbox memo="Laboratory/Imaging Results Request" name="LabsRads" value=""][conditional field="LabsRads" condition="(LabsRads).is('')"][checkbox memo="Laboratory Results" name="Labs" value=""][/conditional][conditional field="Labs" condition="(Labs).is('')"]Laboratory Results Request
-Labs done: [text size="50"]
-Reason these labs were ordered: [text size="80"]
-How long ago these labs were ordered/done: [text size="50"]
-Specialty seen by patient that ordered them: [text size="50"]
[text size="60"][comment memo="add'l comments"][/conditional]
[conditional field="LabsRads" condition="(LabsRads).is('')"][checkbox memo="Imaging Results" name="Rads" value=""][/conditional][conditional field="Rads" condition="(Rads).is('')"]
Imaging Results Request
-Imaging study(s) done: [text size="50"]
-Reason this/these were ordered: [text size="80"]
-Specialty seen by patient that ordered them: [text size="50"]
[text size="60"][comment memo="add'l comments"]
[/conditional]
[comment memo="For use in CRDAMC FM Clinic"]
Miscellaneous Non-acute Patient Requests
yo requesting-
Referral Request
Medication Refill Request




Laboratory/Imaging Results Request

For use in CRDAMC FM Clinic
Result - Copy and paste this output: