|
HPI
|
|
|
Free Text Notes
|
|
|
No Red Flag Symptoms
|
|
|
Sexual orientation and number of partners
|
|
|
Onset: *
• • •
|
|
|
Severity*
|
|
|
Course*
• • •
|
|
|
Fever
|
|
|
Urinary Symptoms (Patient Reports)
• • •
|
Urinary Symptoms (Patient Denies)
• • •
|
|
Other GU Symptoms (patient reports)
• • •
|
Other GU Symptoms (patient denies)
• • •
|
|
GU Comments
|
|
|
Treatments Tried
|
|
|
Last Menstrual Period
|
|
|
Previous forms of birth control
|
|
|
Desired outcome of birth control
|
|
|
Birth Control Risk Factors/contraindications
• • •
|
|
|
REVIEW OF SYSTEMS
|
|
|
General WNL
|
|
|
General (patient reports having)
• • •
|
General (patient denies)
• • •
|
|
General Comments
|
|
|
HEENT WNL
|
|
|
HEENT ROS Comments
|
|
|
Neck/Glands WNL
|
|
|
Neck/Glands ROS Comments
|
|
|
Cardiac WNL
|
|
|
Cardiac (patient reports having)
• • •
|
Cardiac (patient denies)
• • •
|
|
Cardiac ROS Comments
|
|
|
Respiratory WNL
|
|
|
Respiratory (patient reports having)
• • •
|
Respiratory (patient denies)
• • •
|
|
Respiratory ROS Comments
|
|
|
Abdomen/GI WNL
|
|
|
Abdomen / GI (patient reports having)
• • •
|
Abdomen / GI (patient denies)
• • •
|
|
Abdomen/GI ROS Comments
|
|
|
Urinary WNL
|
|
|
Urinary (patient reports having)
• • •
|
Urinary (patient denies)
• • •
|
|
Urinary ROS Comments
|
|
|
Genital (Female) WNL
|
|
|
Genital (Female reports having)
• • •
|
Genital (Female denies)
• • •
|
|
Genital (Male) WNL
|
|
|
Genital (Male reports having)
• • •
|
Genital (Male) denies
• • •
|
|
Genital Comments:
|
|
|
Skin WNL
|
|
|
Skin (patient reports having)
• • •
|
Skin (patient denies)
• • •
|
|
Skin ROS Comments
|
|
|
Mental health
|
|
|
Mental health additional notes
|
|
|
|
|
|
Additional ROS Comments
|
|
|
All systems otherwise negative.
|
|
|
PHYSICAL EXAM
|
|
|
General WNL
|
|
|
General (positive findings)
• • •
|
General (negative findings)
• • •
|
|
General Findings
|
|
|
HEENT (Video) WNL
|
|
|
HEENT (In-Person) WNL
|
|
|
HEENT (positive findings)
• • •
|
HEENT (negative findings)
• • •
|
|
HEENT Findings
|
|
|
Neck/Glands (Video) WNL
|
|
|
Neck/Glands (In-Person) WNL
|
|
|
Neck/Glands (positive findings)
• • •
|
Neck/Glands (negative findings)
• • •
|
|
Neck/Glands Findings
|
|
|
CV (In-Person) WNL
|
|
|
CV IN-PERSON (Positive findings)
• • •
|
CV In-Person (Negative findings)
• • •
|
|
CV Findings
|
|
|
Respiratory (Video) WNL:
|
|
|
Respiratory (In-Person) WNL
|
|
|
Respiratory (Positive findings)
• • •
|
Respiratory (Negative findings)
• • •
|
|
Respiratory Findings
|
|
|
Abdominal (Video) WNL
|
|
|
Abdominal (In-Person) WNL
|
|
|
Abdominal (positive findings)
• • •
|
Abdominal (negative findings)
• • •
|
|
Abdominal/GI Findings
|
|
|
Genital (Exam Deferred)
|
|
|
Skin (Video) WNL
|
|
|
Skin (In-Person) WNL
|
|
|
Skin (positive findings):
• • •
|
Skin (negative findings):
• • •
|
|
Skin Findings
|
|
|
Mental health
|
|
|
Additional System Findings
|
|
