[checkbox value="Constitutional: No fevers, changes in weight, fatigue, night sweats| Head: No headache, sinus congestion or pain| Ears: No ear pain, discharge, hearing loss, tinnitus, vertigo| Eyes No changes in vision, eye pain, diplopia, photophobia| Nose: No nasal discharge, coryza, sneezing, epistaxis| Throat: No cough, sore throat, dysphagia, odynophagia| Skin: No diagnosed skin conditions, new lesions, rashes, discoloration, dryness, hair changes| Heme: No easy bruising, easy bleeding| CV: No chest pain, palpitations, edema, presyncope, decrease in exercise tolerance| Resp: No expectoration, dyspnea with rest or exertion, increased puffer use, orthopnea, PND, wheeze| GI: No abdominal pain, nausea, vomiting, diarrhea, constipation, melena, appetite changes, dyspepsia, belching| GU: No dysuria, frequency, urgency, hematuria, nocturia, incontinence, dribbling, hesitancy, retention, flank pain| Male: Denies discharge, lesions, testicular pain, hernias| Female: Denies discharge, lesions, changes in dysmenorrhea, PMS, menstrual frequency, duration, flow, or symptoms| MSK: No new weakness, arthralgias, myalgias| Neuro: No weakness, confusion, numbness, dizziness, imbalance| Endocrine: No polydipsia, polyuria, heat/cold sensitivity| Pain: No new or unexplained pain| Psychology: No new or worsening depression, anxiety, or insomnia, stress, anger| Social: No change in home, relationships, employment, substance use, exercise, exposure| Function: No change in ADLs or IADLS, memory, capacity"]
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