Subjective/History Elements
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Date of Service: [text name="field_name" default="sample text"]

Patient Type: [text name="field_name" default="sample text"]
Time with Patient: [text name="field_name" default="sample text"]
Type of Visit: [text name="field_name" default="sample text"]

SUBJECTIVE:

CC: [text name="field_name" default="sample text"]

HPI:
Patient is a [text name="field_name" default="sample text"] seen for [text name="field_name" default="sample text"]. Patient has a history of [text name="field_name" default="sample text"]

Patient reports[textarea name="field_name" default="sample text"]

Patient is using [textarea name="field_name" default="sample text"]

Patient has used [textarea name="field_name" default="sample text"]
----------------------------------------------
PMH:

General Health and Strength: [textarea name="field_name" default="sample text"]

Before illness: [textarea name="field_name" default="sample text"]

Impact of illness on lifestyle: [textarea name="field_name" default="sample text"]

Significant Childhood Illnesses: [textarea name="field_name" default="sample text"]Major

Adult Illnesses or Chronic Illnesses: [textarea name="field_name" default="sample text"]

Immunizations:
--Influenza: [text name="field_name" default="sample text"]
--PCV13:[text name="field_name" default="sample text"]
--PPSV23:[text name="field_name" default="sample text"]
--Tdap or Td:[text name="field_name" default="sample text"]
--MMR:[text name="field_name" default="sample text"]
--VAR:[text name="field_name" default="sample text"]
--RZV or ZVL:[text name="field_name" default="sample text"]
--HAV:[text name="field_name" default="sample text"]
--HBV:[text name="field_name" default="sample text"]

Limitation of abilities:
--Hearing: ["Unilateral|Bilateral|sensory loss|neural loss|sensorineural loss|wears hearing aid"]
--Vision: [checklist name="field_name" value="legally blind|glasses|contacts"]
--Speech: [text name="field_name" default="sample text"]
--Gait: [checklist name="field_name" value="frequent falls|cane|tripod cane|quad-cane|walker|wheeled walker|frequent falls|rollator|wheelchair|electric wheelchair"]
--Dexterity: [textarea name="field_name" default="sample text"]
--Swallow: [textarea name="field_name" default="chopped|ground|soft|pureed|nectar thick liquid|honey thick liquid"|full dentures|upper dentures|lower dentures|partials|caps"]


--Exposure to TB: [text name="field_name" default="sample text"]
--Last PPD:[text name="field_name" default="sample text"]
--Other Possible exposures: [text name="field_name" default="sample text"]

--Self-care:[text name="field_name" default="sample text"]
----------------------------------------------
Medications:
[textarea name="field_name" default="sample text"]

Allergies/ADR:
[textarea name="field_name" default="Name/Reaction"]
----------------------------------------------
PSH:
[textarea name="field_name" default="Date, Dx, Hospital, Complications"]
----------------------------------------------
Personal/Social history:
--Place of birth/childhood: [text name="field_name" default="sample text"]
--Places visited: [text name="field_name" default="sample text"]
--Places lived: [text name="field_name" default="sample text"]
--Home Conditions: [text name="field_name" default="sample text"]
--Environment: [text name="field_name" default="sample text"]
--Socioeconomic status: [text name="field_name" default="sample text"]
--Education level: [text name="field_name" default="sample text"]
--Military Record: [text name="field_name" default="sample text"]
--Religious or Cultural Preferences: [text name="field_name" default="sample text"]
--Access to Care: [text name="field_name" default="sample text"]
--Occupations: [text name="field_name" default="sample text"]
--Diet: [text name="field_name" default="sample text"]
--Exercise: [text name="field_name" default="sample text"]
--Smoking History: [text name="field_name" default="sample text"]
--Alcohol Use: [text name="field_name" default="sample text"]
--Illicit Drugs: [text name="field_name" default="sample text"]
--Sexual History: [text name="field_name" default="sample text"]
--Breast Self-Exams: [text name="field_name" default="sample text"]
----------------------------------------------
Family history:
--Mother: [text name="field_name" default="sample text"]
--Father: [text name="field_name" default="sample text"]
--Siblings: [text name="field_name" default="sample text"]
--Children: [text name="field_name" default="sample text"]
--Grandparents:[text name="field_name" default="sample text"]
--Aunts or Uncles: [text name="field_name" default="sample text"]
--Cousins: [text name="field_name" default="sample text"]
----------------------------------------------
Risks:
[textarea name="field_name" default="sample text"]
----------------------------------------------
Date of Service:

Patient Type:
Time with Patient:
Type of Visit:

SUBJECTIVE:

CC:

HPI:
Patient is a seen for . Patient has a history of

Patient reports

Patient is using

Patient has used
----------------------------------------------
PMH:

General Health and Strength:

Before illness:

Impact of illness on lifestyle:

Significant Childhood Illnesses: Major

Adult Illnesses or Chronic Illnesses:

Immunizations:
--Influenza:
--PCV13:
--PPSV23:
--Tdap or Td:
--MMR:
--VAR:
--RZV or ZVL:
--HAV:
--HBV:

Limitation of abilities:
--Hearing: ["Unilateral|Bilateral|sensory loss|neural loss|sensorineural loss|wears hearing aid"]
--Vision:
--Speech:
--Gait:
--Dexterity:
--Swallow:


--Exposure to TB:
--Last PPD:
--Other Possible exposures:

--Self-care:
----------------------------------------------
Medications:


Allergies/ADR:

----------------------------------------------
PSH:

----------------------------------------------
Personal/Social history:
--Place of birth/childhood:
--Places visited:
--Places lived:
--Home Conditions:
--Environment:
--Socioeconomic status:
--Education level:
--Military Record:
--Religious or Cultural Preferences:
--Access to Care:
--Occupations:
--Diet:
--Exercise:
--Smoking History:
--Alcohol Use:
--Illicit Drugs:
--Sexual History:
--Breast Self-Exams:
----------------------------------------------
Family history:
--Mother:
--Father:
--Siblings:
--Children:
--Grandparents:
--Aunts or Uncles:
--Cousins:
----------------------------------------------
Risks:

----------------------------------------------
Result - Copy and paste this output: