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|
Reason for visit (not preset)
|
Reason for visit
• • •
|
|
Screening for
• • •
|
|
|
HPI
|
|
|
Age
|
Medical conditions
• • •
|
|
other medical conditions.
|
Comments
|
|
She/he
• • •
|
|
|
GERD
|
|
|
Year of Diagnosis
|
Treatment
|
|
Comments
|
|
|
Depression
|
|
|
Year of Diagnosis.
|
Treatment.
|
|
Comments.
|
|
|
Anxiety
|
|
|
Year of Diagnosis.
|
Treatment.
|
|
Comments.
|
|
|
Insomnia
|
|
|
Year of Diagnosis.
|
Treatment.
|
|
Comments.
|
|
|
Hypothyroidism
|
|
|
Year of Diagnosis.
|
Treatment.
|
|
Comments.
|
|
|
Fatty liver disease
|
|
|
Year of Diagnosis
|
Comments
|
|
Comments
|
|
|
High Blood Pressure History
|
|
|
Year of Diagnosis
|
Treatment
|
|
blood pressure for years?
|
Comments
|
|
Hyperlipidemia History
|
HLD comments
|
|
Hypercholesterolemia
|
|
|
Year of Diagnosis
|
LDL level.
|
|
Treatment
|
Comments
|
|
Pre-diabetes
|
|
|
Year of Diagnosis
|
Treatment
|
|
Pre-DM comments
|
Complications
• • •
|
|
Diabetes history
|
|
|
Year of Diagnosis
|
diabetes for years?
|
|
Treatment
|
DM comments
|
|
Complications
• • •
|
|
|
OSA history/Screen
|
|
|
Year of Diagnosis
|
Year of sleep study
|
|
Weight at diagnosis
|
Treatment
• • •
|
|
OSA Comments
|
|
|
MK/Injury History
|
MK/Injury history
|
|
Location/Region
• • •
|
|
|
Quality
|
|
|
Severity / Intensity
|
|
|
Duration
|
|
|
Onset/Timing
|
|
|
Context
|
|
|
Modifying Factors
|
|
|
Associated Symptoms
|
|
|
Previous Treatment
|
|
