{
    "section": "subjective",
    "templateSet": "Medicare Annual Well Visit",
    "templates": [
        {
            "text": "Reason for visit",
            "template": "Patient presents for {children}.",
            "children": [
                {
                    "text": "annual wellness visit",
                    "template": "annual wellness visit"
                },
                {
                    "text": "additional concerns include (specify)",
                    "template": "additional patient concerns include {text}",
                    "type": "alpha"
                }
            ]
        },
        {
            "text": "Language\/Communication",
            "template": "Language\/Communication: {children}.",
            "children": [
                {
                    "text": "no communication or language barriers",
                    "template": "no communication or language barriers"
                },
                {
                    "text": "communication\/language barrier (describe)",
                    "template": "{text}",
                    "type": "alpha"
                }
            ]
        },
        {
            "text": "ETOH Hx",
            "template": "ETOH Hx: {children}.",
            "children": [
                {
                    "text": "no alcohol use hx",
                    "template": "no alcohol use hx"
                },
                {
                    "text": "alcohol abuse",
                    "template": "alcohol abuse",
                    "type": "plus-minus"
                },
                {
                    "text": "alcohol dependence",
                    "template": "alcohol dependence",
                    "type": "plus-minus"
                },
                {
                    "text": "drinks per day (#)",
                    "template": "{text} drinks per day",
                    "type": "number"
                },
                {
                    "text": "drinks per week (#)",
                    "template": "{text} drinks per week",
                    "type": "number"
                },
                {
                    "text": "duration, months (#)",
                    "template": "has been drinking for the past {text} months",
                    "type": "number"
                },
                {
                    "text": "duration, years (#)",
                    "template": "has been using for the past {text} years",
                    "type": "number"
                },
                {
                    "text": "quite using (time ago)",
                    "template": "quite using alcohol {text} ago",
                    "type": "alpha"
                },
                {
                    "text": "alcohol withdrawal",
                    "template": "alcohol withdrawal",
                    "type": "plus-minus"
                },
                {
                    "text": "alcohol remission",
                    "template": "alcohol remission",
                    "type": "plus-minus"
                },
                {
                    "text": "hx of dependence (describe)",
                    "template": "{text}",
                    "type": "alpha"
                },
                {
                    "text": "additional alcohol hx (describe)",
                    "template": "{text}",
                    "type": "alpha"
                }
            ]
        },
        {
            "text": "Tobacco Hx",
            "template": "Tobacco Hx: {children}.",
            "children": [
                {
                    "text": "nonsmoker",
                    "template": "nonsmoker"
                },
                {
                    "text": "tobacco abuse",
                    "template": "tobacco abuse",
                    "type": "plus-minus"
                },
                {
                    "text": "tobacco dependence",
                    "template": "tobacco dependence",
                    "type": "plus-minus"
                },
                {
                    "text": "tobacco products used",
                    "template": "tobacco products used include {children}",
                    "children": [
                        {
                            "text": "cigarettes",
                            "template": "cigarettes"
                        },
                        {
                            "text": "cigars",
                            "template": "cigars"
                        },
                        {
                            "text": "pipes",
                            "template": "pipes"
                        },
                        {
                            "text": "water pipes",
                            "template": "water pipes"
                        },
                        {
                            "text": "chew",
                            "template": "chew"
                        },
                        {
                            "text": "snuff",
                            "template": "snuff"
                        }
                    ]
                },
                {
                    "text": "packs per day (specify)",
                    "template": "{text} packs per day",
                    "type": "number"
                },
                {
                    "text": "age at smoking onset (specify)",
                    "template": "started smoking at age {text}",
                    "type": "number"
                },
                {
                    "text": "smoking duration (months)",
                    "template": "smoking duration is {text} months",
                    "type": "number"
                },
                {
                    "text": "smoking duration (years)",
                    "template": "smoking duration is {text} years",
                    "type": "number"
                },
                {
                    "text": "tobacco withdrawal",
                    "template": "tobacco withdrawal",
                    "type": "plus-minus"
                },
                {
                    "text": "tobacco remission",
                    "template": "tobacco remission",
                    "type": "plus-minus"
                },
                {
                    "text": "hx of nicotine dependence (describe)",
                    "template": "{text}",
                    "type": "alpha"
                },
                {
                    "text": "second hand smoke type\/exposure (describe)",
                    "template": "{text}",
                    "type": "alpha"
                },
                {
                    "text": "other (describe)",
                    "template": "{text}",
                    "type": "alpha"
                }
            ]
        },
        {
            "text": "Illicit Drug Hx",
            "template": "Illicit Drug Hx: {children}.",
            "children": [
                {
                    "text": "no illicit drug use hx",
                    "template": "no illicit drug use hx"
                },
                {
                    "text": "illicit drug abuse",
                    "template": "illicit drug abuse",
                    "type": "plus-minus"
                },
                {
                    "text": "illicit drug dependence",
                    "template": "illicit drug dependence",
                    "type": "plus-minus"
                },
                {
                    "text": "type",
                    "template": "{children}",
                    "children": [
                        {
                            "text": "amphetamines",
                            "template": "amphetamines",
                            "type": "plus-minus"
                        },
                        {
                            "text": "cannibis",
                            "template": "cannibis",
                            "type": "plus-minus"
                        },
                        {
                            "text": "cocaine",
                            "template": "cocaine",
                            "type": "plus-minus"
                        },
                        {
                            "text": "ecstasy",
                            "template": "ecstasy",
                            "type": "plus-minus"
                        },
                        {
                            "text": "hallucinogens",
                            "template": "hallucinogens",
                            "type": "plus-minus"
                        },
                        {
                            "text": "heroin",
                            "template": "heroin",
                            "type": "plus-minus"
                        },
                        {
                            "text": "LSD",
                            "template": "LSD",
                            "type": "plus-minus"
                        },
                        {
                            "text": "prescription drugs",
                            "template": "prescription drugs",
                            "type": "plus-minus"
                        },
                        {
                            "text": "sedatives",
                            "template": "sedatives",
                            "type": "plus-minus"
                        },
                        {
                            "text": "stimulants",
                            "template": "stimulants",
                            "type": "plus-minus"
                        },
                        {
                            "text": "street drugs",
                            "template": "street drugs",
                            "type": "plus-minus"
                        }
                    ]
                },
                {
                    "text": "frequency per day (#)",
                    "template": "{text} times per day",
                    "type": "number"
                },
                {
                    "text": "frequency per week (#)",
                    "template": "{text} times per week",
                    "type": "number"
                },
                {
                    "text": "duration, years (#)",
                    "template": "has been using for the past {text} years",
                    "type": "number"
                },
                {
                    "text": "duration, months (#)",
                    "template": "has been using for the past {text} months",
                    "type": "number"
                },
                {
                    "text": "quit using (time ago)",
                    "template": "quite using {text} ago",
                    "type": "alpha"
                },
                {
                    "text": "illicit drug withdrawal",
                    "template": "illicit drug withdrawal",
                    "type": "plus-minus"
                },
                {
                    "text": "illicit drug remission",
                    "template": "illicit drug remission",
                    "type": "plus-minus"
                },
                {
                    "text": "hx of dependence (describe)",
                    "template": "{text}",
                    "type": "alpha"
                },
                {
                    "text": "additional illicit drug use hx (describe)",
                    "template": "{text}",
                    "type": "alpha"
                }
            ]
        },
        {
            "text": "Exercise\/Diet",
            "template": "Exercise\/Diet: {children}.",
            "children": [
                {
                    "text": "exercise type\/frequency\/duration (describe)",
                    "template": "{text}",
                    "type": "alpha"
                },
                {
                    "text": "healthy balanced meals",
                    "template": "healthy balanced meals",
                    "type": "plus-minus"
                },
                {
                    "text": "low-fat diet",
                    "template": "low-fat diet",
                    "type": "plus-minus"
                },
                {
                    "text": "low sodium diet",
                    "template": "low sodium diet",
                    "type": "plus-minus"
                },
                {
                    "text": "caffeine",
                    "template": "caffeine",
                    "children": [
                        {
                            "text": "never",
                            "template": "never",
                            "type": "plus-minus"
                        },
                        {
                            "text": "occasional",
                            "template": "occasional",
                            "type": "plus-minus"
                        },
                        {
                            "text": "daily",
                            "template": "daily",
                            "type": "plus-minus"
                        }
                    ]
                },
                {
                    "text": "other diet comments (describe)",
                    "template": "{text}",
                    "type": "alpha"
                }
            ]
        },
        {
            "text": "Home Environment\/Occupation",
            "template": "Occupation\/Home Environment: {children}.",
            "children": [
                {
                    "text": "residence is in private home",
                    "template": "residence is in private home"
                },
                {
                    "text": "residence is in assisted living",
                    "template": "residence is in assisted living"
                },
                {
                    "text": "other residence (describe)",
                    "template": "{text}",
                    "type": "alpha"
                },
                {
                    "text": "currently retired",
                    "template": "currently retired"
                },
                {
                    "text": "employed (specify occupation)",
                    "template": "employed at",
                    "type": "alpha"
                }
            ]
        },
        {
            "text": "Immunizations",
            "template": "Immunizations: {children}.",
            "children": [
                {
                    "text": "immunizations up to date",
                    "template": "immunizations up to date"
                },
                {
                    "text": "see record for vaccine hx",
                    "template": "see immunization record for vaccine history"
                },
                {
                    "text": "not performed due to",
                    "template": "immunizations not performed due to",
                    "children": [
                        {
                            "text": "contrication",
                            "template": "contrication"
                        },
                        {
                            "text": "compromised condition",
                            "template": "compromised condition"
                        },
                        {
                            "text": "acute illness",
                            "template": "acute illness"
                        },
                        {
                            "text": "chronic illness",
                            "template": "chronic illness"
                        },
                        {
                            "text": "allergy of vaccine or component",
                            "template": "allergy of vaccine or component"
                        },
                        {
                            "text": "religious belief or group pressure",
                            "template": "religious belief or group pressure"
                        },
                        {
                            "text": "patient refusal",
                            "template": "patient refusal"
                        },
                        {
                            "text": "parent\/caregiver refusal",
                            "template": "parent\/caregiver refusal"
                        }
                    ]
                },
                {
                    "text": "other immunizations (describe)",
                    "template": "{text}",
                    "type": "alpha"
                }
            ]
        },
        {
            "text": "Advance Directive",
            "template": "Advanced Directive: {children}.",
            "children": [
                {
                    "text": "review\/agreed upon with patient",
                    "template": "advanced directive reviewed and agreed upon with patient"
                },
                {
                    "text": "on file\/in documents section of EHR",
                    "template": "copy of advanced directive in documents section of the EHR"
                },
                {
                    "text": "family aware and agrees with advance directive",
                    "template": "family aware and agrees with advance directive"
                },
                {
                    "text": "not on file",
                    "template": "patient has advance directive, no copy of directive on file"
                },
                {
                    "text": "no adv. directive\/provided end life discussion",
                    "template": "no advanced directive, discussed end of life planning with patient"
                },
                {
                    "text": "other advance directive (comments)",
                    "template": "{text}",
                    "type": "alpha"
                }
            ]
        },
        {
            "text": "Depression Risk Factors",
            "template": "Risk Factors for Depression: {children}.",
            "children": [
                {
                    "text": "no history of depression or mood disorders",
                    "template": "no history of depression or mood disorders"
                },
                {
                    "text": "chronic medical illness",
                    "template": "chronic medical illness",
                    "type": "plus-minus"
                },
                {
                    "text": "chronic pain syndrome",
                    "template": "chronic pain syndrome",
                    "type": "plus-minus"
                },
                {
                    "text": "chronic minor daily stress",
                    "template": "chronic minor daily stress",
                    "type": "plus-minus"
                },
                {
                    "text": "depression hx",
                    "template": "depression hx",
                    "type": "plus-minus"
                },
                {
                    "text": "job loss",
                    "template": "job loss",
                    "type": "plus-minus"
                },
                {
                    "text": "low income",
                    "template": "low income",
                    "type": "plus-minus"
                },
                {
                    "text": "low self-esteem",
                    "template": "low self-esteem",
                    "type": "plus-minus"
                },
                {
                    "text": "decreased social support",
                    "template": "decreased social support",
                    "type": "plus-minus"
                },
                {
                    "text": "marital status single\/divorce\/widow",
                    "template": "marital status single\/divorce\/widow",
                    "type": "plus-minus"
                },
                {
                    "text": "traumatic brain injury",
                    "template": "traumatic brain injury",
                    "type": "plus-minus"
                },
                {
                    "text": "current depression\/mood disorders",
                    "template": "current depression\/mood disorders:",
                    "type": "alpha"
                },
                {
                    "text": "hx of depression\/mood disorders",
                    "template": "hx of depression\/mood disorders:",
                    "type": "alpha"
                },
                {
                    "text": "reported\/observed risk factors (describe)",
                    "template": "{text}",
                    "type": "alpha"
                }
            ]
        },
        {
            "text": "[PHQ-2, In the past 2 weeks]",
            "template": "[PHQ-2, In the past 2 weeks]"
        },
        {
            "text": "1. Little interest or pleasure in doing things",
            "template": " PHQ-2Over the past 2 weeks, how often have you been bothered by any of the\n                        following problems? 1. Little interest or pleasure in doing things: {children}.\n                    ",
            "children": [
                {
                    "text": "No",
                    "template": "No"
                },
                {
                    "text": "Yes (if Yes, complete PHQ-9)",
                    "template": "Yes"
                }
            ]
        },
        {
            "text": "2. Feeling down, depressed or hopeless",
            "template": "2. Feeling down, depressed or hopeless: {children}.",
            "children": [
                {
                    "text": "No",
                    "template": "No"
                },
                {
                    "text": "Yes (if Yes, complete PHQ-9)",
                    "template": "Yes"
                }
            ]
        },
        {
            "text": "PHQ-9 Score (#)",
            "template": "PHQ-9 Score: {children}.",
            "children": [
                {
                    "text": "PHQ-9 (score)",
                    "template": "{text}",
                    "type": "number"
                },
                {
                    "text": "other PHQ-9 comments (describe)",
                    "template": "{text}",
                    "type": "alpha"
                }
            ]
        },
        {
            "text": "1. Provider\/supplier type (specify)",
            "template": "Current providers and suppliers involved in patient's medical treatment1.\n                        {text}.\n                    ",
            "type": "alpha"
        },
        {
            "text": "2. Provider\/supplier type (specify)",
            "template": "2. {text}.",
            "type": "alpha"
        },
        {
            "text": "3. Provider\/supplier type (specify)",
            "template": "3. {text}.",
            "type": "alpha"
        },
        {
            "text": "4. Provider\/supplier type (specify)",
            "template": "4. {text}.",
            "type": "alpha"
        },
        {
            "text": "5. Provider\/supplier type (specify)",
            "template": "5. {text}.",
            "type": "alpha"
        }
    ]
}