Referrals/Meds/Tests Request HPI

[comment memo="Miscellaneous Non-acute Patient Requests
" memo_size="small" memo_color="blue"][text size="3"]yo [select value="M|F"] requesting-
[checkbox memo="*" memo_size="small" memo_color="blue" name="Referral" value="Referral Request #1"][conditional field="Referral" condition="(Referral).is('Referral Request #1')"]
-Referral to [select memo="specialty" memo_size="small" memo_color="yellow" value="|Neurologist|Sleep Medicine Specialist|Psychiatrist|Psychologist|Ophthalmologist|Otolaryngologist/ENT|Oral Surgeon|Cardiologist|Pulmonologist|General Surgeon|Gastroenterologist|Nephrologist|Urologist|Obstetrician|Gynecologist|Orthopedist|Pain Management Specialist|Physical Therapist|Chiropractor|Hematologist|Oncologist|Endocrinologist|Rheumatologist|Dermatologist|Plastic Surgeon"][text memo="freetext" memo_size="small" memo_color="yellow" size="50"]
-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('Referral Request #1')"]
-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('Referral Request #1')"]
-Additional comments: [textarea default="none"]

[checkbox memo="*" memo_size="small" memo_color="blue" name="Referral2" value="Referral Request #2"][/conditional][conditional field="Referral2" condition="(Referral2).is('Referral Request #2')"]
-Referral to [select memo="specialty" memo_size="small" memo_color="yellow" value="|Neurologist|Sleep Medicine Specialist|Psychiatrist|Psychologist|Ophthalmologist|Otolaryngologist/ENT|Oral Surgeon|Cardiologist|Pulmonologist|General Surgeon|Gastroenterologist|Nephrologist|Urologist|Obstetrician|Gynecologist|Orthopedist|Pain Management Specialist|Physical Therapist|Chiropractor|Hematologist|Oncologist|Endocrinologist|Rheumatologist|Dermatologist|Plastic Surgeon"][text memo="freetext" memo_size="small" memo_color="yellow" size="50"]
-Patient has previously seen this specialty: [select name="New2" value="Yes|No"]
-Patient has previously been seen by a specialist here in the local area: [select name="COC11" value="No|Yes"][/conditional][conditional field="COC11" condition="(COC11).is('Yes')"]
-Patient desires to continue being seen by this same provider: [select name="COC22" value="No|Yes"][/conditional][conditional field="COC22" condition="(COC22).is('Yes')"]
-Provider Name, Practice Name, FAX, Address: [textarea][/conditional][conditional field="Referral2" condition="(Referral2).is('Referral Request #2')"]
-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="New2" condition="(New2).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="Referral2" condition="(Referral2).is('Referral Request #2')"]
-Additional comments: [textarea default="none"]

[checkbox memo="*" memo_size="small" memo_color="blue" name="Referral3" value="Referral Request #3"][/conditional][conditional field="Referral3" condition="(Referral3).is('Referral Request #3')"]
-Referral to [select memo="specialty" memo_size="small" memo_color="yellow" value="|Neurologist|Sleep Medicine Specialist|Psychiatrist|Psychologist|Ophthalmologist|Otolaryngologist/ENT|Oral Surgeon|Cardiologist|Pulmonologist|General Surgeon|Gastroenterologist|Nephrologist|Urologist|Obstetrician|Gynecologist|Orthopedist|Pain Management Specialist|Physical Therapist|Chiropractor|Hematologist|Oncologist|Endocrinologist|Rheumatologist|Dermatologist|Plastic Surgeon"][text memo="freetext" memo_size="small" memo_color="yellow" size="50"]
-Patient has previously seen this specialty: [select name="New3" value="Yes|No"]
-Patient has previously been seen by a specialist here in the local area: [select name="COC111" value="No|Yes"][/conditional][conditional field="COC111" condition="(COC111).is('Yes')"]
-Patient desires to continue being seen by this same provider: [select name="COC222" value="No|Yes"][/conditional][conditional field="COC222" condition="(COC222).is('Yes')"]
-Provider Name, Practice Name, FAX, Address: [textarea][/conditional][conditional field="Referral3" condition="(Referral3).is('Referral Request #3')"]
-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="New3" condition="(New3).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="Referral3" condition="(Referral3).is('Referral Request #3')"]
-Additional comments: [textarea default="none"]

[/conditional][checkbox memo="*" memo_size="small" memo_color="blue" name="Meds1" value="Medication Refill Request #1"][conditional field="Meds1" condition="(Meds1).is('Medication Refill Request #1')"]
-Condition/diagnosis that is being treated with medication: [text size="60"]
-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"]. 
-Additional comments: [textarea default="none"]

[checkbox memo="*" memo_size="small" memo_color="blue" name="Meds2" value="Medication Refill Request #2"][/conditional][conditional field="Meds2" condition="(Meds2).is('Medication Refill Request #2')"]
-Condition/diagnosis that is being treated with medication: [text size="60"]
-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"]. 
-Additional comments: [textarea default="none"]

[checkbox memo="*" memo_size="small" memo_color="blue" name="Meds3" value="Medication Refill Request #3"][/conditional][conditional field="Meds3" condition="(Meds3).is('Medication Refill Request #3')"]
-Condition/diagnosis that is being treated with medication: [text size="60"]
-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"]. 
-Additional comments: [textarea default="none"]

[checkbox memo="*" memo_size="small" memo_color="blue" name="Meds4" value="Medication Refill Request #4"][/conditional][conditional field="Meds4" condition="(Meds4).is('Medication Refill Request #4')"]
-Condition/diagnosis that is being treated with medication: [text size="60"]
-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"]. 
-Additional comments: [textarea default="none"]

[checkbox memo="*" memo_size="small" memo_color="blue" name="Meds5" value="Medication Refill Request #5"][/conditional][conditional field="Meds5" condition="(Meds5).is('Medication Refill Request #5')"]
-Condition/diagnosis that is being treated with medication: [text size="60"]
-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"]. 
-Additional comments: [textarea default="none"]

[/conditional][checkbox memo="*" memo_size="small" memo_color="blue" name="TestRes1" value="Test Results Request #1"][conditional field="TestRes1" condition="(TestRes1).is('Test Results Request #1')"]
-Test(s) done: [text size="60"]
-Reason test(s) were ordered: [text size="80"]
-How long ago test(s) were ordered/done: [text size="50"]
-Specialty/doctor that ordered them for patient: [text size="50"]
[text size="60"]
-Additional comments: [textarea default="none"]

[checkbox memo="*" memo_size="small" memo_color="blue" name="TestRes2" value="Test Results Request #2"][/conditional][conditional field="TestRes2" condition="(TestRes2).is('Test Results Request #2')"]
-Test(s) done: [text size="60"]
-Reason test(s) were ordered: [text size="80"]
-How long ago test(s) were ordered/done: [text size="50"]
-Specialty/doctor that ordered them for patient: [text size="50"]
[text size="60"]
-Additional comments: [textarea default="none"]

[checkbox memo="*" memo_size="small" memo_color="blue" name="TestRes3" value="Test Results Request #3"][/conditional][conditional field="TestRes3" condition="(TestRes3).is('Test Results Request #3')"]
-Test(s) done: [text size="60"]
-Reason test(s) were ordered: [text size="80"]
-How long ago test(s) were ordered/done: [text size="50"]
-Specialty/doctor that ordered them for patient: [text size="50"]
[text size="60"]
-Additional comments: [textarea default="none"]

[/conditional][checkbox memo="labs/rads/studies" memo_size="small" memo_color="blue" name="StudiesReq1" value="Test Order Request #1"][conditional field="StudiesReq1" condition="(StudiesReq1).is('Test Order Request #1')"]
-Test(s) requested: [text size="80"]
-Reason test(s) requested: [text size="80"]
-For which condition or diagnosis is this request (if applicable): [text default="n/a" size="80"]
-When was patient last seen by doctor that is managing this condition: [text size="60"]
-Additional comments: [textarea default="none"]

[checkbox memo="labs/rads/studies" memo_size="small" memo_color="blue" name="StudiesReq2" value="Test Order Request #2"][/conditional][conditional field="StudiesReq2" condition="(StudiesReq2).is('Test Order Request #2')"]
-Test(s) requested: [text size="80"]
-Reason test(s) requested: [text size="80"]
-For which condition or diagnosis is this request (if applicable): [text default="n/a" size="80"]
-When was patient last seen by doctor that is managing this condition: [text size="60"]
-Additional comments: [textarea default="none"]

[checkbox memo="labs/rads/studies" memo_size="small" memo_color="blue" name="StudiesReq3" value="Test Order Request #3"][/conditional][conditional field="StudiesReq3" condition="(StudiesReq3).is('Test Order Request #3')"]
-Test(s) requested: [text size="80"]
-Reason test(s) requested: [text size="80"]
-For which condition or diagnosis is this request (if applicable): [text default="n/a" size="80"]
-When was patient last seen by doctor that is managing this condition: [text size="60"]
-Additional comments: [textarea default="none"]

[/conditional][comment memo="For use in CRDAMC FM Clinic" memo_size="small"]