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History of Present Illness
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Patient is here for a follow-up
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Patient has diabetes
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Glucose readings
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A1c reading
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Compliant with medications
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Compliance with diet
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Has neuropathy symptoms
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Has had a recent eye exam
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Has low glucose readings
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Has a podiatrist
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Free text field for diabetes
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Has hypertension
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Blood pressure readings
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Compliant with medications
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Is on low salt diet
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Has had the following symptoms
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Reports no symptoms
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Free text field for hypertension
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Has hyperlipidemia
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Compliant with medications
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Compliance with diet
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Lipids have gone up
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Has recent cholesterol labs
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Free text field for hyperlipidemia
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Has Congestive Heart Failure
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Compliant with medications
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Weigh gain
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Has had edema
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Has had shortness of breath
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Has had the following symptoms
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Free text field for CHF
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Has Chronic Kidney Disease
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Patient is followed by a Nephrologist
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Patient has had a decrease in urination
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Is avoiding nephrotoxic drugs such as NSAIDs.
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Patient's creatinine trend
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Free text field for CKD
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Impaired fasting glucose
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Compliance with diet
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Has lost weight.
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Following a regular exercise routine
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Free text field for impaired fasting glucose
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Hypothyroidism
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Compliant with medications
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They have no symptoms.
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Has the following symptoms
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Free text field for hypothyrodism
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Free text field for follow-up
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Patient is here for a CPE
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Compliant with medications
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Patient has been working on diet and exercise
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Labs show the followig
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Is up to date on colonoscopy
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Is up to date on mammogram
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Up to date on pap smear
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Is up to date on bone density
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Free text field for CPE
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Patient is here for joint injection
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Which joint
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Diagnosed with
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risk benefits
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Free text for joint injection
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Lesion removal
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How long has had lesion
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Has changed in size or shape
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Characteristics of lesion
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Has history of prior skin cancers
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Free text field for lesion removal
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New patient visit
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Has had a previous primary care physician
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Reviewed past medical records
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Free text field for new patient visit
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Has complaints
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Neurologic complaints (HA, seizure, numbness, weakness)
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Headache
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How long have been gong on
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location of headache
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Intensity of pain out of 10
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Photophobia
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Nausea or vomiting
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Has had prior migraines
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Worst headache of life
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Stiff neck
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fevers
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Visual changes
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Has no neurologic deficits
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Free text for headache
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Seizure like episode
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How long have been gong on
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When was last one
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How long did episode last
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Fall during episode
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Loss of conscious
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Loss of bowel or bladder control
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Episode was witnessed
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Witness description
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Happened before
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Prior neurologist
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Episode described as
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Free text for seizure
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Numbness
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locations of numbness
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How long has been gong on
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Constant or intermittent
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Effected by position
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Weakness with the numbness
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Back pain with the numbness
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What medication taken for numbness in past?
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Free text for numbness
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Has had weakness
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Location of weakness
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Has had frequent falls
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How long have been gong on
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Started when
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Difficult to get out of chair
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Has pain in back or neck
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Active in daily life
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Onset gradual or sudden
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Free text for weakness
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Musculoskeletal (Joint Pain, Back Pain, Muscle Pain)
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Joint pain
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Joint pain is in
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Intensity of pain out of 10
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Started when
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How long has been gong on
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Onset gradual or sudden
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Swelling in joint
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Redness of joint
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Joint warm
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Injury to joint
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How long ago was injured
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Method of injury
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Has taken over the counter medication
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Name or type of medication
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Medication has helped
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Getting better with time
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Free text for joint pain
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Back pain
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Started when
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Intensity of pain out of 10
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Onset gradual or sudden
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How long has been gong on
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Injury to back
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Method of injury
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Has taken over the counter medication
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Name or type of medication
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Medication has helped
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Getting better with time
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Loss of bowel or bladder control
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Has numbness in legs
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Weakness in the legs
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Has radiation of pain down leg
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Worse with sitting or standing
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Free text for back pain
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Muscle pain
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Started when
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How long has been gong on
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Onset gradual or sudden
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Intensity of pain out of 10
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Injury to muscle.
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Method of injury
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Has taken over the counter medication
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Name or type of medication
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Medication has helped
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Getting better with time
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Also has weakness
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Rash
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Gets worse with movement
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Free text field for muscle pain
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Geriatric issues (memory loss, weight loss, frequent falls)
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Memory loss
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How long have been gong on
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Onset gradual or sudden
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Any long term memory loss
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Specific things forgotten
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Still has interest in current events
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Name two current events
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Has sun downing
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Has had hallucinations
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Has had signs of an infection
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Has shown signs of a stroke
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Free text for memory loss
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Unexplained weight loss
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Period of time that weight loss has occurred
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amount lost (just number in pounds)
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Appetite normal (if not normal is decreased)
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Change in bowel habits
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Shown following signs of bowel disease
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Signs of hyperthyroidism
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Patient has history of smoking
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Is up to date on all cancer screening
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Free text for weight loss
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Frequent falls
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How long has been gong on
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Onset gradual or sudden
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Do legs feel weak
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Loses balance
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Has dizziness
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Feel like going to pass out
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Uses an assistive device
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Free text for frequent falls
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Syncope (both true syncope and dizziness)
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Dizziness or blacking out
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Made worse by moving head
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Worse when standing up from sitting
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If blacked out was it witnessed
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Description from witness
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Any heart palpitations
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Nausea or vomiting with episodes
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Any chest pain
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Loss of bowel or bladder control
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Ringing in ears
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Free text for syncope and dizziness
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GU issues (UTI, frequent urination, kidney stones)
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UTI
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How long have been gong on
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Onset gradual or sudden
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Has taken over the counter medication
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Name or type of medication
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Burning with urination
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Urinary frequency
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Has urgency
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flank pain
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Has had fevers
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temperature of fever
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Has seen blood in the urine
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Free text for UTI
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Has frequent urination or urinary incontinence
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Sometimes incontinent of urine
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When does incontinence occur
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How often urinating during the day
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How often urinating at night
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Urinating large amount or small amount
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Difficult to start a stream
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How long has been gong on
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Free text for urinary incontinence and frequency
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Has a possible kidney stone
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Has had flank pain
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description of pain
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How long has been gong on
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Onset gradual or sudden
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Intensity of pain out of 10
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Has taken over the counter medication
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Name or type of medication
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Medication has helped
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Getting better with time
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Has seen blood in urine
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Has had fevers
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Free text field for kidney stones
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Pulmonary issues (SOB/dyspnea, COPD, Asthma, chronic cough)
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Shortness of breath
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How long has been gong on
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Onset gradual or sudden
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constant or intermittent
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Worse with exertion
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Has orthopnea or PND
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Peripheral edema
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chest pain
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Cough
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prior history of
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Text field for SOB
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COPD or asthma
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COPD or asthma
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They are compliant with their inhalers
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How many times in a week using albuterol
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night time symptoms
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Cough
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has quit smoking
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Recent exacerbations
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See's a pulmonologist
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Recent PFTs
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Free text for COPD or asthma
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Chronic cough
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How long has been gong on
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Has taken over the counter medication
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Name or type of medication
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Medication has helped
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Getting better with time
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Cough is productive
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Has had fevers
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Is on an ACE or ARB
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Has nasal drainage
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Has had shortness of breath
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has had GERD symptoms
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Free text for chronic cough
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Cardiovascular (chest pain, palpitations, swelling)
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Chest pain
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How long has been going on
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Intensity of pain out of 10
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description of the pain
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Worse with exertion
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How long does it last
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Associated symptoms
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risk factors
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has known CAD
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Pain gets worse with movement
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Chest wall tender
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Worse with deep inspiration
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Free text for chest pain
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Palpitations or racing heart beat
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How long has been gong on
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How long does episode last
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Feel lightheaded
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Pass out
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shortness of breath
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chest pain
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How often per week
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resolve on own
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Does this to get it to stop
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Free text palpitations
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Swelling
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How long has been gong on
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Onset gradual or sudden
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Any new medications
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The new mediation is
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Has orthopnea or PND
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Cough
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Any weight gain
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How much weight gain in pounds
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Has been eating high salt diet
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Location of the swelling
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Has been helping it by
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Has helped
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Free text for swelling
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GI issues (abdominal pain, N/V/D, GERD, blood in stool, dysphagia)
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Abdominal pain
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How long has been gong on
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Intensity of pain out of 10
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description of pain
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Has taken over the counter medication
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Name or type of medication
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Medication has helped
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Onset gradual or sudden
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duration of pain
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Associated symptoms
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Location of the pain
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Free text field for adominal pain
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N/V/D
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Patient has had the following symptoms
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How long has been gong on
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Onset gradual or sudden
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Has taken over the counter medication
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Name or type of medication
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Medication has helped
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Description of diarrhea
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Has blood in diarrhea
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Has had fevers
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Has had weight loss
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Ate from unusual food source
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Where ate
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Sick contacts
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Free text for N/V/D
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GERD symptoms
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How long has been gong on
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Has taken over the counter medication
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Name or type of medication
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Medication has helped
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Associated symptoms
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Has had an EGD in the past
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How long ago
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Eats the following diet
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Has tried
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Free text for GERD
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Blood in stool
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How long has been gong on
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The amount
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The color of the is
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Patient has other associated symptoms
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Prior colonoscopy
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Free text for blood in stool
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Dysphagia
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Difficulty swallowing what texture
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How long has been gong on
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Onset gradual or sudden
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Has had an EGD in the past
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Associated symptoms
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Free text for Dysphagia
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Dermatology (rash, skin lesion)
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Rash
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How long has been gong on
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Has had fevers
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Itches
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Spreading
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Other family members with rash
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Has it changed
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No new soaps, detergents, medications, etc.
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Has been in contact with
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Has taken over the counter medication
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Name or type of medication
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Medication has helped
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Other symptoms
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Free text field for rash
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Skin lesion
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How long has had lesion
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Has changed in size or shape
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Characteristics of lesion
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Characteristics of lesion
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Has history of prior skin cancers
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Free text field for lesion removal
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HEENT (ear pain, hoarseness, decrease hearing, allergies)
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Ear pain
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Which ear
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How long has been gong on
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Intensity of pain out of 10
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Onset gradual or sudden
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description of pain
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Has taken over the counter medication
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Name or type of medication
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Medication has helped
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has other associated symptoms
• • •
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Free text field for ear pain
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Hoarseness
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How long has been gong on
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Onset gradual or sudden
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Getting better with time
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Has taken over the counter medication
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Name or type of medication
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Medication has helped
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Has had fevers
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Has had cough
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has a runny nose
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sore throat
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Has known GERD or symptoms of GERD
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History of smoking
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Free text for hoarseness
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Decrease hearing
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Associated symptoms
• • •
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Free text for decrease in hearing
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Allergies
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How long has been gong on
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Onset gradual or sudden
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Has had fevers
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Has taken over the counter medication
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Name or type of medication
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Medication has helped
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Symptoms consistent with allergies
• • •
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Free text for allergies
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URI
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How long has been gong on
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Has had fevers
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Has taken over the counter medication
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Name or type of medication
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Medication has helped
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cough
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cough is productive or not
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runny nose
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Stuffy nose
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Body aches or chills
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Sore throat
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sick contacts
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Free text for URI
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Psychiatric (Depression, anxiety, ADD, insomnia)
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Depression
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How long has been gong on
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Symptoms consistentwith depression
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No suicidal or homicidal ideation
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Free text for depression
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Anxiety
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How long has been gong on
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Has had panic attacks
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Onset gradual or sudden
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Any inciting events
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Free text for anxiety
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ADD
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How long has been gong on
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Diagnosed previously in the past
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Unable to concentrate
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ADD free text
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