Examination yes
Lower extremity edema
Upper extremity edema
Varicose veins
Observable deformities
Visible wounds
yes Activity Days/week min/day
Walking
Swimming
Aerobic activities
Other
yes reason
Cardiac arrest
MI
Stroke
Dysrhythmias
DVT
Pulmonary embolism
Pneumonia
Leak
Poor oral intake/food intolerance
Other
yes Complication onset after surgery (in weeks) treatment
GE reflux
Flatulence
Persistent diarrhea
Constipation
Dehydration
Nausea/vomiting
Abdominal pain
yes Drug duration of use (weeks)
Heparin
Warfarin
Iron
Folate
Vitamin D
Calcium
Zinc
Multi-vitamins
Pantoprazole/ Omeprazole
Antacids
Painkillers
Ursodiol
yes Drug Form Count Desc.
Anti-diabetic agents
Antihypertensive drugs
Lipid-lowering agents
Corticosteroids
Cardiac drugs
Neurologic/Psychiatric medication
Anti-arthritic/Discopathy drugs
Thyroid drugs
Antiasthma/Apnea drugs
Liver disease medications
Other (specify)
yes Drugs Value
Metformin
Glibenclamide
Gliclazide
Glitazone
Acarbose
Other oral agents
yes Drugs Value
Insulin Regular
Insulin NPH
Insulin Glargine (Lantus)
Insulin Aspart (Novorapid)
yes Drugs Value
Triamterene H
Hydrochlorothiazide
Spironolactone
Furosemide
Atenolol
Metoprolol/Propranolol
Carvedilol
Metoral
Prazosin/ terazosin
Verapamil
Diltiazem
Nifedipine
Amlodipine
Captopril/ Enalapril/ lisinopril
Losartan/ Valsartan
Other oral antihypertensives
yes Drugs Value
Furosemide
Other parenteral anti-hypertensive
yes Drugs Value
Clofibrate/Simfibrate
Gemfibrozil
Cholestyramine/ Calcitriol
Colestipol
Nicotinic acid
Niacin
Atorvastatin/ Lovastatin
Fluvastatin/ Simvastatin
Ezetimibe
Other
yes Drugs Value
Hydrocortisone
Prednisolone
Betamethasone
Dexamethasone
yes Drugs Value
Hydrocortisone
Prednisolone
Methyl prednisolone
Betamethasone
Dexamethasone
Triamcinolone
Examination yes
Lower extremity edema
Upper extremity edema
Varicose veins
Deformities
Wounds


Comorbidities yes
Hypertension
Diabetes
CHF
Asthma
History of thromboembolism
Sleep apnea
Ischemic heart disease
Stroke
Angina
Cardiac surgery
Psychiatric disease
Liver Disease
Osteoarthritis
Discopathy
Other
yes Ischemic heart status
History of MI
Abnormal ECG
PCI, CABG
Drug treatment for IHD
yes Stroke status
Sensory
Motor
Verbal disturbance
Cognitive and memory loss
yes Stroke status
OCD
Anxiety disorder
Depression
Other
yes Endoscopy
Barrett’s esophagus
Hiatal hernia
H-Pylori infection
Peptic ulcer disease
GERD
yes Endoscopy
Para esophageal hernia
Hiatal hernia
Ulcer
yes Endoscopy
Normal sinus rhythm
Atrial Fib
Sinus tachycardia
Other arrhythmias
ST-T wave changes/Possible ischemia
Other (specify)