Well Woman Encounter HPI
[comment memo="Use with well woman questionnaire"] [text size="3"] yo G[text size="2"] P[text size="2"] with LMP of [text size="10"] here for well-woman exam. -Last Pap- [text size="3"] years ago. Results: [select value="normal|other- "][text size="40"] -Hx of abnormal Pap test: [select value="no|YES"][text size="40"] -Menarche at age [text size="3"] -Age of menopause: [select name="menopause" value="not yet reached|started withing past 1/2yrs|"][conditional field="menopause" condition="(menopause).isNot('not yet reached')"] [text size="4"] [/conditional][conditional field="menopause" condition="(menopause).is('not yet reached')"] -Frequency of menstrual cycles- every [text size="8"] days? -Menstrual cycle regularity- [select value="regular|irregular"] -Duration of menses- [text size="8"] days -Amount of bleeding on heaviest days- [text size="4"] pads/tampons per day -Between cycle bleeding- [select value="no|YES"] [/conditional]-Unusual vaginal discharge- [select value="no|YES"] -Sexually active- [select name="Sex" value="no|Yes"][conditional field="Sex" condition="(Sex).is('Yes')"] -Number of sexual partners in past year *[text size="3"]*[/conditional] -Current method(s) of birth control? [checkbox value="None|Condoms|Withdrawal method|Calendar method (timing intercourse around ovulation)|Birth control pills|Birth control patch (OrthoEvra)|Vaginal ring (NuvaRing)|Injection (DepoProvera)|Diaphragm|Nexplanon|Mirena|Tubal Ligation|Hysterectomy|Post-menopausal|Other-"] [text size="20"] -History of STD?- [select value="no|YES"] -Problematic hot flashes- [select value="no|YES"] -Currently on hormone replacement- [select value="no|YES"] -Smoking- [select value="no|YES"] -Hx of breast problems- [select value="no|YES"] -Last mammogram- [select value="n/a|date-"] [text size="20"] -Reports being abused- [select value="no|YES"] -Feels safe at home? [select value="yes|NO"] -Family history of: --Breast cancer- [select value="no|YES"] --Ovarian cancer- [select value="no|YES"] --Heart disease- [select value="no|YES"] --Osteoporosis- [select value="no|YES"] --Diabetes- [select value="no|YES"] --Other cancers- [select value="no|YES"] --Colon cancer- [select value="no|YES"] --Uterine cancer- [select value="no|YES"] -Allergies- [select value="NKDA|listed-"] [text size="80"] -Pain during your usual period: [select value="1|2|3|4|5|6|7|8|9|10"]/10 -Pain during sex: [select value="1|2|3|4|5|6|7|8|9|10"]/10 -PMS (premenstrual tension syndrome): [select value="1|2|3|4|5|6|7|8|9|10"]/10 Other concerns: [textarea] [comment memo="For use in CRDAMC FM Clinic"]
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 0.62, 50 form elements, 94 boilerplate words, 16 text boxes, 1 text areas, 1 checkboxes, 27 drop downs, 2 comments, 3 conditionals, 59 total clicks
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