|
HPI Template: (1 of first 6 required)
• • •
|
|
|
New Insurance Patient?
|
Existing Patient? (Non-global)
|
|
Insurance Global Period
|
New Cosmetic Patient?
|
|
PostOp Visit
|
New unrelated, concern
|
|
POD
|
Day/Week/Month
|
|
Procedure
• • •
|
other procedure name
|
|
Concerns? (if yes, elaborate in comments)
|
Specify Concern(s) (Full sentences)
|
|
Pain free recovery? (if no, elaborate)
|
Pain Level
• • •
|
|
Referred?
|
Referring Provider Name
|
|
Referring Provider
• • •
|
PCP
|
|
Skin cancer
|
Biopsy results
• • •
|
|
Skin Cancer Visit Type
• • •
|
Prior history of skin ca?
|
|
ENT problem
|
ENT Symptoms
• • •
|
|
Prior medication treatments (if yes, elaborate in comments)
|
Prior medications
• • •
|
|
Previous sinus surgery? (if yes, elaborate in comments)
|
Previous sinus surgery comments
|
|
Trauma
|
Cause of trauma
• • •
|
|
Cosmetic Consultation
|
Cosmetic Concern
• • •
|
|
Accompanied by
• • •
|
Accompaniment Comment
|
|
Custom HPI: (complete sentences)
|
Washing with...
• • •
|
|
Onset began...
• • •
|
days/weeks/months ago
• • •
|
|
Location Area
• • •
|
Location Anatomical
|
|
Free text location:
|
Location Comments (Full sentences)
|
|
Onset / Timing
• • •
|
Onset Comments (Full sentences)
|
|
Pain Quality
• • •
|
Quality Comments (full sentences)
|
|
Severity
|
Severity Comments (Full sentences)
|
|
Duration
• • •
|
Duration Comments (Full sentences)
|
|
Modifying Factors***
• • •
|
Modifying Factors Comments (Full sentences)
|
|
Context***
• • •
|
Context Comments (Full sentences)
|
|
Associated Symptoms***
• • •
|
Associated Symptoms (list only)
|
|
Comments (full sentences)
|
Photos
|
|
Delete
|
|
|
|
Concern Comments
|
|
Day/Week/Month
|
Previous Treatment(s)
|
|
New Insurance Patient?
|
|
