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Gyne Intake Form

Updated April 2013

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<html>
<title>Initial Gynecologic Consult</title>
<head>

<!--- Created April 2013, Written for version 12.0, No Image, Uses "eform magic" to write to encounter, pushes and pulls measurements for use in other areas, has a nullip button for setting all pregnancy values to 0 with code in header to put initial values in to form, uses check boxes to write in to text spaces --->

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    if (document.getElementById("A").value ==''){
		(document.getElementById("A").value = 0);
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</head>

<body onload = 'start();'>
<form method="post" action="" name="FormName">


<!-- ---------------------------Hidden inputs   ------ -->
<input type="hidden" name="history1" id="history1"  oscarDB=OngoingConcerns>
<input type="hidden" name="history2" id="history2"  oscarDB=Medical_History>
<input type="hidden" name="history3" id="history3"  oscarDB=Other_Medications_History>
<input class="nodisplay" type="hidden" name="counter" id = "counter" >
<input type="hidden" name="date" id="date"  oscardb=today >
<input type="hidden" name="age" id="age"  oscardb=age >

<!-- ---------------------- -->


<p class="title">
	Initial Gynecolgic Consult
</p>


<table width="800">
	<tr>
		<td class="heading1"  colspan="2">Patient Demographics:</td>
	</tr>
	<tr>
		<td class="normaltext" colspan="2"><textarea name="Demographics" class="formtext" style="height:100;" oscarDB=age> yo</textarea></td>
	</tr>
	<tr>
		<td class="heading2">Previous MD</td>
		<td class="normaltext"><input class="formtext" name="PrevMD" type="text"></td>
	</tr>
</table>


<table width="800">
	<tr>
		<td class="heading2">Chief Complaint</td>
		<td class="normaltext"><input class="formtext" name="m$CC#value" id="CC" type="text"  onblur="subject.value=CC.value"; oscarDB=m$CC#value></td>
	</tr>
	<tr>
		<td class="heading1" colspan="2">Problem List</td>
	</tr>
	<tr>
		<td class="normaltext" colspan="2"><textarea name="Current" id="Current" class="formtext" style="height: 200;" wrap="virtual"></textarea></td>
	</tr>
</table>

<table width="800">
	<tr>
		<td class="heading1" colspan="2">History of Present Illness </td>
	</tr>
	<tr>
		<td class="normaltext" colspan="2"><textarea name="m$HPI#value" class="formtext" style="height: 200;" wrap="virtual" oscarDB=m$HPI#value></textarea></td>
	</tr>
</table>

<table width="800">
	<tr>
		<td class="heading1" colspan="2">Past History</td>
	</tr>
	<tr>
		<td class="normaltext" colspan="2"><textarea name="MedicalHistory" id="MedicalHistory" class="formtext" style="height: 200;" wrap="virtual" ></textarea></td>
	</tr>
	<tr>
		<td class="heading2">Anesthetic Problems</td>
		<td><textarea name="AnestheticProblems" class="formtext" style="height:20;"></textarea></td>
	</tr>
	<tr>
		<td class="heading2">Transfusions?</td>
		<td><textarea name="m$TRAN#value" class="formtext" style="height:20;"oscarDB=m$TRAN#value></textarea></td><td>Yes/No</td>
	</tr>
	<tr>
		<td class="heading2">Sleep Apnea?</td>
		<td><textarea name="m$SLAP#value" class="formtext" style="height:20;" oscarDB=m$SLAP#value></textarea></td><td>Yes/No</td>
	</tr>
</table>
<table width="800">
	<tr>
		<td class="heading1" colspan="2">OB/GYN History</td>
	</tr>
	<tr>
		<td class="normaltext" colspan="2">
		<form>
			G<input name="m$G#value" id="m$G#value" type="text" class="formtext" style="width:20;" oscarDB=m$G#value>
			P<input name="m$P#value" id="m$P#value" type="text" class="formtext" style="width:20;" oscarDB=m$P#value>
			T<input name="m$TERM#value" id="m$TERM#value" type="text" class="formtext" style="width:20;" oscarDB=m$TERM#value>
			A<input name="A" id="A" type="text" class="formtext" style="width:20;">
			(SA<input name="m$SA#value" id="m$SA#value" type="text" class="formtext" style="width:20;" oscarDB=m$SA#value>
			TA<input name="m$TOP#value" id="m$TOP#value" type="text" class="formtext" style="width:20;"oscarDB=m$TOP#value>)
			L<input name="m$LIVE#value" id="m$LIVE#value" type="text" class="formtext" style="width:20;"oscarDB=m$LIVE#value>
		<input   class="DoNotPrint" type="button"   onclick="nulligravida()"   value="Click if Nulligravida" />
		</td>
	</tr>
	<tr>
		<td class="heading2">Menses</td>
		<td><input name="Menses" type="text" class="formtext"></td>
	</tr>
	<tr>
		<td class="heading2">Pap</td>
		<td class="normaltext">
			<input name="PapAlwaysNormal" type="checkbox" onclick="document.getElementById('Pap').value='Always Normal'">Always Normal 
			<input name="PapAbnormal" type="checkbox" onclick="document.getElementById('Pap').value='Abnormal'">Abnormal 
			&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Cytology Number <input name="m$CYTO#value" type="text" class="formtext" style="width:200;"oscarDB=m$CYTO#value>
			<input name="Pap" id="Pap" type="text" class="formtext"></td>
	</tr>

	<tr>
		<td class="heading2">STDs</td>
		<td><input name="STDs" type="text" class="formtext"></td>
	</tr>
	<tr>
		<td class="heading2">Contraceptions</td>
		<td>
			<table width="100%">
				<tr><td><input name="m$BCTR#value" type="text" class="formtext" style="width:50;" oscarDB=m$BCTR#value></td><td  class="normaltext">YES/NO</td><td width="50" class="normaltext">Now</td><td><input name="ContraceptionsNow" type="text" class="formtext"></td></tr>
				<tr><td></td><td></td><td width="50" class="normaltext">Past</td><td><input name="ContraceptionsPast" type="text" class="formtext"></td></tr>
			</table>
		</td>
	</tr>
	<tr>
		<td class="heading2">Blood type</td>
		<td><input name="BloodType" class="formtext" type="text"></td>
	</tr>
	<tr>
		<td class="heading2">Problems in Pregnancy</td>
		<td class="normaltext"><textarea name="ProblemsInPregnancy" class="formtext" style="height:50;"></textarea></td>
	</tr>
	<tr>
		<td class="heading2">Menopause</td>
		<td><input name="Meopause" class="formtext" type="text"></td>
	</tr>
	<tr>
		<td class="heading2">Calcium & Vitamin D</td>
		<td><input name="CalciumVitD" class="formtext" type="text"></td>
	</tr>
</table>

<table width="800">
	<tr>
		<td class="heading1" colspan="2">Medications</td>
	</tr>
	<tr>
		<td class="normaltext" colspan="2"><textarea name="druglist_generic"  class="formtext" style="height: 200;" wrap="virtual"  oscarDB=druglist_generic ></textarea></td>
	</tr>
	<tr>
		<td class="heading2">Allergies</td>
		<td><textarea name="Allergies" class="formtext" style="height:20;" oscarDB=allergies_des_no_archived></textarea></td>
	</tr>
	<tr>
		<td class="heading2">Latex Allergy?</td>
		<td><textarea name="m$LATX#value" class="formtext" style="height:20;"oscarDB=m$LATX#value></textarea></td><td>Yes/No</td>
	</tr>
	<tr>
		<td class="heading2">Adverse Reactions</td>
		<td><textarea name="AdverseReactions" class="formtext" style="height:20;"></textarea></td>
	</tr>

</table>

<table width="800">
	<tr>
		<td class="heading1" colspan="2">Family History</td>
	</tr>
	<tr>
		<td class="normaltext">
			<input name="Mom" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Mother-'">Mom
			<input name="Dad" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Father-'">Dad
			<input name="Wife" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Wife-'">Wife
			<input name="Husband" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Husband-'">Husband
			<input name="Son" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Son-'">Son
			<input name="Daughter" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Daughter-'">Daughter
			<input name="Sister" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Sister-'">Sis
			<input name="Broher" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Brother-'">Bro
			<input name="Aunt" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Aunt-'">Aunt
			<input name="Uncle" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Uncle-'">Uncle
			<input name="Grandmother" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Grandmother-'">Grandma
			<input name="Grandfather" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Grandfather-'">Grandpa
			<br>
		</td>
	</tr>
	<tr>
		<td class="normaltext">
			<input name="BP" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='High Blood Pressure, '">BP
			<input name="CVA" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Cerebral Vascular Accidents, '">CVA
			<input name="MI" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Myocardial Infarction, '">MI
			<input name="Lipid" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Hyperlipidemia, '">Lipid
			<input name="DM" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Diabetes, '">DM
			<input name="Thyr" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Thyroid Disease, '">Thyr
			<input name="Ca" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Cancer, '">Ca
			<input name="BreastCa" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Breast Cancer, '">Breast Ca
			<input name="Glauc" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Glaucoma, '">Glauc
			<input name="GI" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Gastrointestinal Problems, '">GI
			<input name="GU" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='GenitoUrinary Problems, '">GU
			<input name="MSK" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='MusculoSkeletal Problems, '">MSK
			<input name="Resp" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Respiratory Illness, '">Resp
			<input name="Allegy" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Allergies, '">Allergy
			<input name="EtOH" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Alcohol Abuse, '">EtOH
			<input name="Psych" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Psychiatric Illness, '">Psych
			<br>
			<textarea name="SocialFamilyHistory" id="SocialFamilyHistory" class="formtext" style="height:100;"></textarea>
		</td>
	</tr>
</table>

<table width="800">
	<tr>
		<td class="heading1" colspan="2">Lifestyle</td>
	</tr>
	<tr>
		<td class="heading2">Smoking</td>
		<td class="normaltext">
			<input name="m$SMK#value" type="text" class="formtext" style="width:50;" oscarDB=m$SMK#value> (YES/No)
			<input name="NeverSmoked" type="checkbox" >Never
			<input name="Quit" type="checkbox" >Quit
			<input name="OccasionalSmoke" type="checkbox" >Occ
			<input name="OccasionalSmoke" type="checkbox" >Now
			<input name="m$NOSK#value" type="text" class="formtext" style="width:30px;height:20px;" oscarDB=m$NOSK#value>/day
			&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Start:<input name="StartSmoke" type="text" class="formtext" style="width:50px; height:20px;">
			&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Quit:<input name="QuitSmoke" type="text" class="formtext" style="width:50px; height:20px;">
		</td>
	</tr>
	<tr>
		<td class="heading2">Caffeine</td>
		<td class="normaltext">
			<input name="Caffeine" type="text" class="formtext" style="width:100;">/day
		</td>
	</tr>
	<tr>
		<td class="heading2">Alcohol</td>
		<td class="normaltext">
			<input name="m$ALC#value" type="text" class="formtext" style="width:50;" oscarDB=m$ALC#value> (YES/No)
			<input name="m$DRPW#value" type="text" class="formtext" style="width:50;" oscarDB=m$DRPW#value> /wk
		</td>
	</tr>
	<tr>
		<td class="heading2">Drugs</td>
		<td class="normaltext">
			<input name="IVDU" type="checkbox" onclick="document.getElementById('Drugs').value+='IV Drug Use, '">IVDU
			<input name="Drugs" id="Drugs" type="text" class="formtext" style="width:500;">
		</td>
	</tr>
	<tr>
		<td class="heading2">Diet</td>
		<td class="normaltext"><input name="Diet" type="text" class="formtext"></td>
	</tr>
	<tr>
		<td class="heading2">Fitness</td>
		<td class="normaltext"><input name="Fitness" type="text" class="formtext"></td>
	</tr>
</table>
<table width="800">
	<tr>
		<td class="heading1" colspan="2">Social History</td>
	</tr>
	<tr>
		<td class="heading2">Relationship Status</td>
		<td class="normaltext">
			<input name="Single" type="checkbox">Single
			<input name="Married" type="checkbox">Married
			<input name="CommonLaw" type="checkbox">Common Law
			<input name="Separated" type="checkbox">Separated
			<input name="Divorced" type="checkbox">Divorced
			<input name="Widowed" type="checkbox">Widowed
		</td>
	</tr>
	<tr> 
		<td class="heading2">Partner's Name</td>
		<td class="normaltext"><input name="PartnerName" type="text" class="formtext"></td>
	</tr>
	<tr>
		<td class="heading2">Sexual Partners</td>
		<td class="normaltext">
			<input name="PartnerM" type="checkbox">M 
			<input name="PartnerF" type="checkbox">F 
			<input name="PartnerBoth" type="checkbox">Both 
			<input name="PartnerNone" type="checkbox">None 
		</td>
	</tr>
	<tr>
		<td class="heading2">Sexual Concern</td>
		<td class="normaltext">
			<input name="SexualConcerns" type="text" class="formtext">
		</td>
	</tr>
	<tr>
		<td class="heading2">Assault/Abuse</td>
		<td class="normaltext">
			<input name="m$ASLT#value" type="text" class="formtext" style="width:50;" oscarDB=m$ASLT#value>Yes/No
		</td>
	</tr>
	<tr>
		<td class="heading2">Counseling?</td>
		<td class="normaltext">
			<input name="Counseling" type="text" class="formtext">
		</td>
	</tr>
	<tr>
		<td class="heading2">Education</td>
		<td class="normaltext">
			<input name="Education" type="text" class="formtext">
		</td>
	</tr>
	<tr>
		<td class="heading2">Occupation</td>
		<td class="normaltext">
			<input name="Occupation" type="text" class="formtext">
		</td>
	</tr>
</table>



<table width="800">
	<tr>
		<td class="heading1" colspan="2">Examination</td>
	</tr>
	<tr class="heading2">
		<td class="heading2">Measurements</td>
		<td class="normaltext">
			HT<input name="m$HT#value" type="text" class="formtext" style="width:50;" oscarDB=m$HT#value> (cm)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
			WT<input name="m$WT#value" type="text" class="formtext" style="width:50;" oscarDB=m$WT#value> (kg)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
			BMI<input name="m$BMI#value" type="text" class="formtext" style="width:50;" oscarDB=m$BMI#value> (kg/m<sup>2</sup>)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
			BP<input name="m$BP#value" type="text" class="formtext" style="width:50;" oscarDB=m$BP#value> (sitting) &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
		</td>
	</tr>
	<tr class="heading2">
		<td class="heading2">Routine Exam</td>
		<td class="normaltext">
					<table width="100%">
						<tr><td class="normaltext"> H&N <input name="m$HN#value" type="text" class="formtext" style="width:50;" oscarDB=m$HN#value> (N/Abn)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
						Chest<input name="m$CHST#value" type="text" class="formtext" style="width:50;" oscarDB=m$CHST#value>(N/Abn)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
						CVS<input name="m$CVS#value" type="text" class="formtext" style="width:50;" oscarDB=m$CVS#value>(N/Abn)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
						Abd<input name="m$ABD#value" type="text" class="formtext" style="width:50;" oscarDB=m$ABD#value>(N/Abn)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</td></tr>
						<tr><td class="normaltext">Pelvic<input name="m$PELV#value" type="text" class="formtext" style="width:75%;" oscarDB=m$PELV#value>(N/Abn/Disc)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</td></tr>
						<tr><td class="normaltext"> QTip <input name="m$QTIP#value" type="text" class="formtext" style="width:125;" oscarDB=m$QTIP#value> (>30, <30)&nbsp;&nbsp;&nbsp;
						Post Void Residual<input name="m$PVRV#value" type="text" class="formtext" style="width:125;" oscarDB=m$PVRV#value>(N less than 100cc)&nbsp;&nbsp;&nbsp;
					</table>	
		</td>
</tr>
</table>
<table width="800">
	<tr>
		<td class="heading1"  colspan="2">Assessment:</td>
	</tr>
	<tr>
		<td class="normaltext" colspan="2"><textarea name="m$SES#value" class="formtext" style="height:100;"></textarea></td>
	</tr>
</table>
<table width="800">
	<tr>
		<td class="heading1"  colspan="2">Plan:</td>
	</tr>
	<tr>
		<td class="normaltext" colspan="2"><textarea name="m$PLAN#value" class="formtext" style="height:100;"></textarea></td>
	</tr>
</table>
<table width="800">
	<tr>
		<td class="heading1"  colspan="2">Procedure:</td>
	</tr>
	<tr>
		<td class="normaltext" colspan="2"><textarea name="m$PROC#value" class="formtext" style="height:100;"></textarea></td>
	</tr>
</table>



<!-- The submit/print/reset buttons ------------------------------------------------------------->
<div name="FunctionButtons" class="DoNotPrint">
<table>
<tr>
	<td class="subjectline">
		Subject: <input name="subject" size="40" type="text">
		<input value="Submit" name="SubmitButton" type="submit">
		<input value="Reset" name="ResetButton" type="reset">
		<input value="Print" name="PrintButton" onclick="javascript:window.print()" type="button">
	</td>
</tr>
</table>
</div>

</form>
<!-- ------End of submit/print/reset buttons----------------------------------------------------->


</body>
</html>
<!--
<template>
 <encounternote>
 $t{age} yo G $t{m$G#value} P $t{m$P#value} SA $t{m$SA#value} TOP $t{m$TOP#value}
 
 CC: $t{m$CC#value}
 
 HPI: $t{m$HPI#value}
 
 Menses: $t{Menses}
 
 Pap: $t{Pap}
 
 Contraception: $t{ContraceptionsNow}
 
 Occupation: $t{Occupation}
 
 PMHx: $t{MedicalHistory}
 
 GA prob? $t{AnestheticProblems}
 
 Trans? $t{m$TRAN#value}
 
 App? $t{m$SLAP#value}
 
 Meds: $t{druglist_generic}
 
 Allergies: $t{Allergies}
 
 Latex: $t{m$LATX#value}
 
 $t{m$NOSK#value} Cigarettes per day,  $t{m$DRPW#value} Drinks per week , Drugs $t{Drugs}, Abuse $t{m$ASLT#value},Couselling $t{Counseling}
 
 ON EXAMINATION
 
 Ht $t{m$HT#value} cm, Wt  $t{m$WT#value} kg, BMI  $t{m$BMI#value} kg/m2
 BP  $t{m$BP#value}
 H&N  $t{m$HN#value} Chest  $t{m$CHST#value}
 CVS  $t{m$CVS#value} Abd  $t{m$ABD#value}
 Pelvis  $t{m$PELV#value}
 Qtip $t{m$QTIP#value}
 Post Void Residual $t{m$PVRV#value}
 
 Assessment $t{m$SES#value}
 
 Plan $t{m$PLAN#value}

 Procedure $t{m$PROC#value}
 
 </encounternote>
 <familyhistory> $t{SocialFamilyHistory} </familyhistory>
 <medicalhistory> $t{MedicalHistory} </medicalhistory>
 <ongoingconcerns> $t{Current} </ongoingconcerns>

</template>
-->

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