Subjective/History Elements
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[comment memo="URI/URTI Upper Respiratory Tract Infection HPI Template"]
[text size="3"]yo [select value="M|F"] with [comment memo="symptoms"][checkbox value="runny nose|stuffy nose|itchy eyes|watery eyes|ear pain|sinus pain in cheeks and/or forehead|sore throat|pain with swallowing|hoarseness|productive cough|dry cough|fever|chills|body aches"] for the past [text size="3"] [select value="day(s)|week(s)"][comment memo="duration"]

Is sore throat the main complaint without concurrent cold-like symptoms (nose/eyes/etc)? [select name="Centor" value="no|YES"][comment memo="Choose 'yes' to bring up Centor Criteria"][conditional field="Centor" condition="(Centor).is('YES')"]

Modified Centor Score
[select name="Q1Fever" value="No (0 points)=0|YES (1 point)=1"] <-- History of fever or measured temperature > 100.4 degrees F
[select name="Q2Cough" value="Cough is present (0 points)=0|COUGH IS ABSENT (1 point)=1"] <-- Presence of coughing
[select name="Q3Nodes" value="No (0 points)=0|YES (1 point)=1"] <-- Tender anterior cervical nodes
[select name="Q4Tonsil" value="No (0 points)=0|YES (1 point)=1"] <-- Tonsillar swelling or exudates
[select name="Q5Age" value="< 15 years (1 point)=1|15 to 45 years (0 points)=0|> 45 years (-1 point)=-1"] <-- Age
Score --> [calc value="score=(Q1Fever)+(Q2Cough)+(Q3Nodes)+(Q4Tonsil)+(Q5Age)" memo="score"][/conditional]

[comment memo="modifying factors"]
Therapies tried that have improved symptoms: [text size="50"]
Therapies tried that have NOT improved symptoms: [text size="50"]

[comment memo="Additional comments:"][textarea]

[comment memo="For use in CRDAMC FM Clinic"]
URI/URTI Upper Respiratory Tract Infection HPI Template
yo with symptoms for the past duration

Is sore throat the main complaint without concurrent cold-like symptoms (nose/eyes/etc)? Choose 'yes' to bring up Centor Criteria

modifying factors
Therapies tried that have improved symptoms:
Therapies tried that have NOT improved symptoms:

Additional comments:

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