1 <!-- Form generated from formsWiz
-->
3 include_once("../../globals.php");
4 include_once("$srcdir/api.inc");
5 formHeader("Form: rosform");
8 <?php
html_header_show();?
>
9 <link rel
="stylesheet" href
="<?php echo $css_header;?>" type
="text/css">
11 <body
class="body_top">
12 <form method
=post action
="<?php echo $rootdir;?>/forms/rosform/save.php?mode=new" name
="my_form">
13 <span
class="title">Review of Systems
</span
><br
><br
>
14 <span
class=bold
>General
</span
><br
>
15 <span
class=text
>Fever
: </span
><input type
=entry name
="fever" value
="" ><br
>
16 <span
class=text
>Chills
: </span
><input type
=entry name
="chills" value
="" ><br
>
17 <span
class=bold
>Skin
</span
><br
>
18 <span
class=text
>Rash
: </span
><input type
=entry name
="rash" value
="" ><br
>
19 <span
class=text
>Cancer
: </span
><input type
=entry name
="cancer" value
="" ><br
>
20 <span
class=text
>Acne
: </span
><input type
=entry name
="acne" value
="" ><br
>
21 <span
class=bold
>Eyes
</span
><br
>
22 <span
class=text
>Diplopia
: </span
><input type
=entry name
="eyes_diplopia" value
="" ><br
>
23 <span
class=text
>Cataracts
: </span
><input type
=entry name
="eyes_cataracts" value
="" ><br
>
24 <span
class=text
>Glaucoma
: </span
><input type
=entry name
="eyes_glaucoma" value
="" ><br
>
25 <span
class=bold
>Head
</span
><br
>
26 <span
class=text
>Dizziness
: </span
><input type
=entry name
="head_dizziness" value
="" ><br
>
27 <span
class=text
>Syncope
: </span
><input type
=entry name
="head_syncope" value
="" ><br
>
28 <span
class=text
>Headache
: </span
><input type
=entry name
="head_headache" value
="" ><br
>
29 <span
class=bold
>Ear
</span
><br
>
30 <span
class=text
>Pain
: </span
><input type
=entry name
="ear_pain" value
="" ><br
>
31 <span
class=text
>Loss
: </span
><input type
=entry name
="ear_loss" value
="" ><br
>
32 <span
class=bold
>Nose
</span
><br
>
33 <span
class=text
>Congestion
: </span
><input type
=entry name
="nose_congestion" value
="" ><br
>
34 <span
class=text
>Epitaxis
: </span
><input type
=entry name
="nose_epitaxis" value
="" ><br
>
35 <span
class=bold
>Throat
</span
><br
>
36 <span
class=text
>Sore
: </span
><input type
=entry name
="throat_sore" value
="" ><br
>
37 <span
class=text
>Dysphagia
: </span
><input type
=entry name
="throat_dysphagia" value
="" ><br
>
38 <span
class=text
>Swollen Glands
: </span
><input type
=entry name
="throat_swollen_glands" value
="" ><br
>
39 <span
class=bold
>Respiratory
</span
><br
>
40 <span
class=text
>Dyspnea
: </span
><input type
=entry name
="respiratory_dyspnea" value
="" ><br
>
41 <span
class=text
>At Rest
: </span
><input type
=entry name
="respiratory_rest" value
="" ><br
>
42 <span
class=text
>At Exertion
: </span
><input type
=entry name
="respiratory_exertion" value
="" ><br
>
43 <span
class=text
>Cough
: </span
><input type
=entry name
="respiratory_cough" value
="" ><br
>
44 <span
class=text
>Asthma
: </span
><input type
=entry name
="respiratory_asthma" value
="" ><br
>
45 <span
class=bold
>Cardiac
</span
><br
>
46 <span
class=text
>Palpitation
: </span
><input type
=entry name
="cardiac_palpitation" value
="" ><br
>
47 <span
class=text
>Heart Murmur
: </span
><input type
=entry name
="cardiac_heart_murmur" value
="" ><br
>
48 <span
class=text
>Chest Pain
: </span
><input type
=entry name
="cardiac_chest_pain" value
="" ><br
>
49 <span
class=text
>Pleuritic
: </span
><input type
=entry name
="cardiac_pleuritic" value
="" ><br
>
50 <span
class=text
>HTN
: </span
><input type
=entry name
="cardiac_htm" value
="" ><br
>
51 <span
class=text
>NTG
Use: </span
><input type
=entry name
="cardiac_ntg_use" value
="" ><br
>
52 <span
class=bold
>HEM LYMPH
</span
><br
>
53 <span
class=text
>Anemia
: </span
><input type
=entry name
="hem_lymph_anemia" value
="" ><br
>
54 <span
class=text
>Nightsweats
: </span
><input type
=entry name
="hem_lymph_nightsweats" value
="" ><br
>
55 <span
class=bold
>GI
</span
><br
>
56 <span
class=text
>Nausea
: </span
><input type
=entry name
="gi_nausea" value
="" ><br
>
57 <span
class=text
>Vomiting
: </span
><input type
=entry name
="gi_vomiting" value
="" ><br
>
58 <span
class=text
>Diarrhea
: </span
><input type
=entry name
="gi_diarrhea" value
="" ><br
>
59 <span
class=text
>Constipation
: </span
><input type
=entry name
="gi_constipation" value
="" ><br
>
60 <span
class=text
>Black Stools
: </span
><input type
=entry name
="gi_black_stools" value
="" ><br
>
61 <span
class=text
>Blood in Stools
: </span
><input type
=entry name
="gi_blood_stools" value
="" ><br
>
62 <span
class=text
>Pain
: </span
><input type
=entry name
="gi_pain" value
="" ><br
>
63 <span
class=text
>Abdominal Pain
: </span
><input type
=entry name
="gi_abdominal_pain" value
="" ><br
>
64 <span
class=bold
>GU
</span
><br
>
65 <span
class=text
>Nocturia
: </span
><input type
=entry name
="gu_nocturia" value
="" ><br
>
66 <span
class=text
>Stream
: </span
><input type
=entry name
="gu_stream" value
="" ><br
>
67 <span
class=text
>Hematuria
: </span
><input type
=entry name
="gu_hematuria" value
="" ><br
>
68 <span
class=text
>Pain
: </span
><input type
=entry name
="gu_pain" value
="" ><br
>
69 <span
class=text
>Incontinence
: </span
><input type
=entry name
="gu_incontinence" value
="" ><br
>
70 <span
class=text
>Frequency
: </span
><input type
=entry name
="gu_frequency" value
="" ><br
>
71 <span
class=bold
>GYN
</span
><br
>
72 <span
class=text
>Lump
: </span
><input type
=entry name
="gyn_lump" value
="" ><br
>
73 <span
class=text
>Checkup
: </span
><input type
=entry name
='gyn_checkup' size
=10 value
='YYYY-MM-DD' ><br
>
74 <span
class=text
>Mammogram
: </span
><input type
=entry name
='gyn_mammogram' size
=10 value
='YYYY-MM-DD' ><br
>
75 <span
class=text
>Sexual
: </span
><input type
=entry name
="sexual" value
="" ><br
>
76 <span
class=bold
>Ortho
</span
><br
>
77 <span
class=text
>Pain
: </span
><input type
=entry name
="ortho_pain" value
="" ><br
>
78 <span
class=text
>Trauma
: </span
><input type
=entry name
="ortho_trauma" value
="" ><br
>
79 <span
class=text
>Neuro
: </span
><input type
=entry name
="ortho_neuro" value
="" ><br
>
80 <span
class=bold
>Endo
</span
><br
>
81 <span
class=text
>Diabetes
: </span
><input type
=entry name
="endo_diabetes" value
="" ><br
>
82 <span
class=text
>Thyroid
: </span
><input type
=entry name
="endo_thyroid" value
="" ><br
>
83 <span
class=bold
>Psych
</span
><br
>
84 <span
class=text
>Sleep Problems
: </span
><input type
=entry name
="psych_sleep_problems" value
="" ><br
>
85 <span
class=text
>Memory Loss
: </span
><input type
=entry name
="psych_memory_loss" value
="" ><br
>
86 <span
class=bold
>Leg
</span
><br
>
87 <span
class=text
>Swelling
: </span
><input type
=entry name
="leg_swelling" value
="" ><br
>
88 <span
class=text
>Numbness
: </span
><input type
=entry name
="leg_numbness" value
="" ><br
>
89 <span
class=bold
>Appearance
</span
><br
>
90 <input type
=checkbox name
='appearance_nad' ><span
class=text
>NAD
</span
><br
>
91 <input type
=checkbox name
='appearance_mild' ><span
class=text
>Mild
</span
><br
>
92 <input type
=checkbox name
='appearance_moderate' ><span
class=text
>Moderate
</span
><br
>
93 <input type
=checkbox name
='appearance_severe_distress' ><span
class=text
>Severe Distress
</span
><br
>
94 <span
class=bold
>Skin
</span
><br
>
95 <span
class=text
>Moles
: </span
><input type
=entry name
="skin_moles" value
="" ><br
>
96 <span
class=text
>Rash
: </span
><input type
=entry name
="skin_rash" value
="" ><br
>
97 <span
class=bold
>Head
</span
><br
>
98 <input type
=checkbox name
='head_ent_nl_inspection' ><span
class=text
>ENT nl inspection
</span
><br
>
99 <input type
=checkbox name
='head_pharynx_nl' ><span
class=text
>Pharynx nl
</span
><br
>
100 <input type
=checkbox name
='head_abn_tm' ><span
class=text
>ABN TM
</span
><br
>
101 <input type
=checkbox name
='head_scleral_icterus' ><span
class=text
>Scleral Icterus
</span
><br
>
102 <span
class=bold
>Eyes
</span
><br
>
103 <span
class=text
>Pupils Right
: </span
><input type
=entry name
="eyes_pupils_right" value
="" ><br
>
104 <span
class=text
>Pupils Left
: </span
><input type
=entry name
="eyes_pupils_left" value
="" ><br
>
105 <span
class=text
>Fundi Right
: </span
><input type
=entry name
="fundi_right" value
="" ><br
>
106 <span
class=text
>Fundi Left
: </span
><input type
=entry name
="fundi_left" value
="" ><br
>
107 <span
class=bold
>Visual Fields
</span
><br
>
108 <input type
=checkbox name
='vision_fields_normal' ><span
class=text
>Normal
</span
><br
>
109 <input type
=checkbox name
='vision_fields_abnormal' ><span
class=text
>Abnormal
</span
><br
>
110 <span
class=bold
>Ears
</span
><br
>
111 <span
class=text
>Right TM
: </span
><input type
=entry name
="ears_right" value
="" ><br
>
112 <span
class=text
>Left TM
: </span
><input type
=entry name
="ears_left" value
="" ><br
>
113 <span
class=text
>Hearing Deficit
: </span
><input type
=entry name
="ears_hearing_deficit" value
="" ><br
>
114 <span
class=bold
>Nose
</span
><br
>
115 <span
class=text
>Erythema
: </span
><input type
=entry name
="nose_erythema" value
="" ><br
>
116 <span
class=text
>Discharge
: </span
><input type
=entry name
="nose_discharge" value
="" ><br
>
117 <span
class=bold
>Throat
</span
><br
>
118 <input type
=checkbox name
='throat_nl' ><span
class=text
>NL
</span
><br
>
119 <input type
=checkbox name
='throat_thyroid_nl' ><span
class=text
>Thyroid nl
</span
><br
>
120 <input type
=checkbox name
='throat_thyromegaly' ><span
class=text
>Thyromegaly
</span
><br
>
121 <input type
=checkbox name
='throat_erytheomatous' ><span
class=text
>Erytheomatous
</span
><br
>
122 <span
class=bold
>Lymph Nodes
</span
><br
>
123 <span
class=text
>Cervical Right
: </span
><input type
=entry name
="lymph_cervical_right" value
="" ><br
>
124 <span
class=text
>Cervical Left
: </span
><input type
=entry name
="lymph_cervical_left" value
="" ><br
>
125 <span
class=text
>Axillary Right
: </span
><input type
=entry name
="lymph_axillary_right" value
="" ><br
>
126 <span
class=text
>Axillary Left
: </span
><input type
=entry name
="lymph_axillary_left" value
="" ><br
>
127 <span
class=text
>Supraclav Right
: </span
><input type
=entry name
="lymph_supraclav_right" value
="" ><br
>
128 <span
class=text
>Supraclav Left
: </span
><input type
=entry name
="lymph_supraclav_left" value
="" ><br
>
129 <span
class=text
>Inguinal Right
: </span
><input type
=entry name
="lymph_inguinal_right" value
="" ><br
>
130 <span
class=text
>Inguinal Left
: </span
><input type
=entry name
="lymph_inguinal_left" value
="" ><br
>
131 <span
class=text
>Carotid Bruits
: </span
><input type
=entry name
="carotid_bruits" value
="" ><br
>
132 <span
class=bold
>Respiratory
</span
><br
>
133 <input type
=checkbox name
='respiratory_no_distress' ><span
class=text
>No disress
</span
><br
>
134 <input type
=checkbox name
='chest_non_tender' ><span
class=text
>Chest non
-tender
</span
><br
>
135 <input type
=checkbox name
='respiratory_distress' ><span
class=text
>Respiratory distress
</span
><br
>
136 <input type
=checkbox name
='respiratory_clear_to_ausc' ><span
class=text
>Clear to ausc
</span
><br
>
137 <input type
=checkbox name
='respiratory_splinting' ><span
class=text
>Splinting
</span
><br
>
138 <input type
=checkbox name
='respiratory_rales' ><span
class=text
>Rales
</span
><br
>
139 <input type
=checkbox name
='respiratory_rhonchi' ><span
class=text
>Rhonchi
</span
><br
>
140 <input type
=checkbox name
='respiratory_wheezing' ><span
class=text
>Wheezing
</span
><br
>
141 <span
class=bold
>Heart
</span
><br
>
142 <input type
=checkbox name
='heart_regular_rate' ><span
class=text
>Regular rate
</span
><br
>
143 <input type
=checkbox name
='heart_irregular_rate' ><span
class=text
>Irregular rate
</span
><br
>
144 <input type
=checkbox name
='heart_murmur' ><span
class=text
>Murmur
</span
><br
>
145 <input type
=checkbox name
='heart_gallop' ><span
class=text
>Gallop
</span
><br
>
146 <input type
=checkbox name
='heart_rub' ><span
class=text
>Rub
</span
><br
>
147 <input type
=checkbox name
='heart_tachy_brady' ><span
class=text
>Tachy
/Brady
</span
><br
>
148 <input type
=checkbox name
='heart_jvd' ><span
class=text
>JVD present
</span
><br
>
149 <input type
=checkbox name
='heart_grade' ><span
class=text
>Grade
</span
><br
>
150 <input type
=checkbox name
='heart_sys_dias' ><span
class=text
>Sys
/Dias
</span
><br
>
151 <span
class=bold
>Breasts
</span
><br
>
152 <span
class=text
>Right Cystic
: </span
><input type
=entry name
="breast_right_cystic" value
="" ><br
>
153 <span
class=text
>Left Cystic
: </span
><input type
=entry name
="breast_left_cystic" value
="" ><br
>
154 <span
class=bold
>Abdomen
</span
><br
>
155 <input type
=checkbox name
='abdomen_non_tender' ><span
class=text
>Non
-tender
</span
><br
>
156 <input type
=checkbox name
='abdomen_no_organomegaly' ><span
class=text
>No organomegaly
</span
><br
>
157 <input type
=checkbox name
='abdomen_guarding' ><span
class=text
>Guarding
</span
><br
>
158 <input type
=checkbox name
='abdomen_rebound' ><span
class=text
>Rebound
</span
><br
>
159 <input type
=checkbox name
='abdomen_bowel_sounds' ><span
class=text
>Abn bowel sounds
</span
><br
>
160 <input type
=checkbox name
='abdomen_hepatomegaly' ><span
class=text
>Hepatomegaly
</span
><br
>
161 <span
class=bold
>Rectal
</span
><br
>
162 <span
class=text
>Prostate
: </span
><input type
=entry name
="rectal_prostate" value
="" ><br
>
163 <span
class=text
>Hemmocult
: </span
><input type
=entry name
="rectal_hemmocult" value
="" ><br
>
164 <input type
=checkbox name
='rectal_tender' ><span
class=text
>Rectal tender
</span
><br
>
165 <input type
=checkbox name
='rectal_hemmorrhoids' ><span
class=text
>Hemmorrhiods
</span
><br
>
166 <span
class=bold
>Genitalia
</span
><br
>
167 <span
class=text
>Hernia
: </span
><input type
=entry name
="genitalia_hernia" value
="" ><br
>
168 <span
class=text
>Ext
. Vagina
: </span
><input type
=entry name
="genitalia_ext_vagina" value
="" ><br
>
169 <span
class=text
>Male
: </span
><input type
=entry name
="genitalia_male" value
="" ><br
>
170 <span
class=text
>Speculum
: </span
><input type
=entry name
="speculum" value
="" ><br
>
171 <span
class=text
>Palpation
: </span
><input type
=entry name
="palpation" value
="" ><br
>
172 <span
class=text
>Uterus
: </span
><input type
=entry name
="uterus" value
="" ><br
>
173 <span
class=text
>Adnexa Right
: </span
><input type
=entry name
="adnexa_right" value
="" ><br
>
174 <span
class=text
>Adnexa Left
: </span
><input type
=entry name
="adnexa_left" value
="" ><br
>
175 <span
class=bold
>Neuro Exam
</span
><br
>
176 <span
class=text
>CN
's: </span><input type=entry name="neuro_exam_cns" value="" ><br>
177 <span class=text>Oriented: </span><input type=entry name="neuro_exam_oriented" value="" ><br>
178 <span class=text>Confused: </span><input type=entry name="neuro_exam_confused" value="" ><br>
179 <span class=text>MMSE: </span><input type=entry name="neuro_exam_mmse" value="" ><br>
180 <span class=text>Muscle Strength: </span><input type=entry name="muscle_strength" value="" ><br>
181 <span class=bold>Reflexes</span><br>
182 <span class=text>RUE: </span><input type=entry name="reflexes_rue" value="" ><br>
183 <span class=text>RLE: </span><input type=entry name="reflexes_rle" value="" ><br>
184 <span class=text>LUE: </span><input type=entry name="reflexes_lue" value="" ><br>
185 <span class=text>LLE: </span><input type=entry name="reflexes_lle" value="" ><br>
186 <span class=text>Vibration: </span><input type=entry name="vibration" value="" ><br>
187 <span class=text>Sensation: </span><input type=entry name="sensation" value="" ><br>
188 <span class=text>Babinski: </span><input type=entry name="babinski" value="" ><br>
189 <span class=text>Edema: </span><input type=entry name="edema" value="" ><br>
190 <span class=text>Varicosities: </span><input type=entry name="varicosities" value="" ><br>
191 <span class=text>Nails: </span><input type=entry name="nails" value="" ><br>
192 <span class=bold>Joints</span><br>
193 <span class=text>Neck: </span><input type=entry name="joints_neck" value="" ><br>
194 <span class=text>Shoulder Right: </span><input type=entry name="joints_shoulder_right" value="" ><br>
195 <span class=text>Shoulder Left: </span><input type=entry name="joints_sholder_left" value="" ><br>
196 <span class=text>Elbow Right: </span><input type=entry name="joints_elbow_right" value="" ><br>
197 <span class=text>Elbow Left: </span><input type=entry name="joints_elbow_left" value="" ><br>
198 <span class=text>Wrist Right: </span><input type=entry name="joints_wrist_right" value="" ><br>
199 <span class=text>Wrist Left: </span><input type=entry name="joints_wrist_left" value="" ><br>
200 <span class=text>Hand Right: </span><input type=entry name="joints_hand_right" value="" ><br>
201 <span class=text>Hand Left: </span><input type=entry name="joints_hand_left" value="" ><br>
202 <span class=text>Hip Right: </span><input type=entry name="joints_hip_right" value="" ><br>
203 <span class=text>Hip Left: </span><input type=entry name="joints_hip_left" value="" ><br>
204 <span class=text>Back Right: </span><input type=entry name="joints_back_right" value="" ><br>
205 <span class=text>Back Left: </span><input type=entry name="joints_back_left" value="" ><br>
206 <span class=text>SLR Right: </span><input type=entry name="joints_slr_right" value="" ><br>
207 <span class=text>SLR Left: </span><input type=entry name="joints_slr_left" value="" ><br>
208 <span class=text>Knee Right: </span><input type=entry name="joints_knee_right" value="" ><br>
209 <span class=text>Knee Left: </span><input type=entry name="joints_knee_left" value="" ><br>
210 <span class=text>Ankle Right: </span><input type=entry name="joints_ankle_right" value="" ><br>
211 <span class=text>Ankle Left: </span><input type=entry name="joints_ankle_left" value="" ><br>
212 <span class=text>Foot Right: </span><input type=entry name="joints_foot_right" value="" ><br>
213 <span class=text>Foot Left: </span><input type=entry name="joints_foot_left" value="" ><br>
214 <span class=bold>Conclusions</span><br>
215 <span class=text>Impression: </span><br><textarea cols=40 rows=8 wrap=virtual name="conclusions_impression" ></textarea><br>
216 <span class=text>Discussion: </span><br><textarea cols=40 rows=8 wrap=virtual name="conclusions_discussion" ></textarea><br>
217 <span class=text>Treatment: </span><br><textarea cols=40 rows=8 wrap=virtual name="conclusions_treatment" ></textarea><br>
218 <input type=checkbox name='conclusions_breast_self_exam
' ><span class=text>Breast Self Exam</span><br>
219 <input type=checkbox name='conclusions_flex_sig_colonoscopy
' ><span class=text>Flex Sig/Colonoscopy</span><br>
220 <input type=checkbox name='conclusions_mammography
' ><span class=text>Mammography</span><br>
221 <input type=checkbox name='conclusions_cholesterol_teaching
' ><span class=text>Cholesterol Teaching</span><br>
222 <input type=checkbox name='conclusions_advance_directive
' ><span class=text>Advance Directive</span><br>
223 <span class=text>Follow-up: </span><br><textarea cols=40 rows=8 wrap=virtual name="follow_up" ></textarea><br>
225 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
227 <a href="<?php echo $GLOBALS['form_exit_url
']; ?>" class="link" onclick="top.restoreSession()">[Don't Save
]</a
>
