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@@ -36,14 +36,8 @@ if ($point->lastChildReview && $point->lastChildReview->data) {
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@include('app.patient.modules._undo_changes', compact('point'))
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<div class="row mb-1">
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- <div class="col-md-12 section">
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- <div class="form-group">
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- <label>Chief Complaint</label>
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- <textarea class="form-control inline flex-grow-1" v-model="data.cheif_complaint"></textarea>
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- </div>
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- </div>
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<div class="col-md-12">
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- <h6 class="my-3"><b><u>Weight History</u></b></h6>
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+ <h6 class="my-3"><b><u>Epworth Sleepiness Scale</u></b></h6>
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</div>
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<div class="col-md-12 section bg-light pt-2 mb-3">
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<div class="form-group">
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@@ -77,707 +71,6 @@ if ($point->lastChildReview && $point->lastChildReview->data) {
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</div>
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</div>
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</div>
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- <div class="col-md-12 section">
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- <div class="form-group">
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- <label>Did you ever gain more than 20 pounds in less than 3 months?</label>
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- <div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="radio" v-model="data.gained_more_than_20_pounds"
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- id="gm-yes" value="yes">
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- <label class="form-check-label" for="gm-yes">Yes</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="radio" v-model="data.gained_more_than_20_pounds"
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- id="gm-no" value="no">
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- <label class="form-check-label" for="gm-no">No</label>
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- </div>
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- </div>
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- <div class="d-flex mt-3">
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- <label>If so, when?</label>
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- <input type="text" class="form-control inline flex-grow-1"
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- v-model="data.gained_more_than_20_pounds_when" />
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- </div>
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- </div>
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- </div>
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- <div class="col-md-12 section">
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- <div class="form-group">
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- <div class="d-flex flex-wrap">
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- <label class="mr-3">How much did you weigh:</label>
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- <div class="d-flex mr-3">
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- <label>one year ago?</label>
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- <input type="text" class="form-control inline width-50px" v-model="data.weight_1_year_ago">
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- </div>
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- <div class="d-flex mr-3">
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- <label>Five years ago?</label>
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- <input type="text" class="form-control inline width-50px" v-model="data.weight_5_years_ago">
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- </div>
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- <div class="d-flex">
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- <label>10 years ago?</label>
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- <input type="text" class="form-control inline width-50px" v-model="data.weight_10_years_ago">
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- </div>
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- </div>
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- </div>
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- </div>
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-
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- <div class="col-md-12 section bg-light pt-2 mb-3">
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- <div class="form-group">
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- <label>Life events associated with weight gain (check all that apply):</label>
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- <div class="unified-checks flex-basis-20">
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.weight_gain_life_events" id="le-marriage" value="marriage">
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- <label class="form-check-label" for="le-marriage">Marriage</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.weight_gain_life_events" id="le-divorce" value="divorce">
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- <label class="form-check-label" for="le-divorce">Divorce</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.weight_gain_life_events" id="le-pregnancy" value="pregnancy">
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- <label class="form-check-label" for="le-pregnancy">Pregnancy</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.weight_gain_life_events" id="le-abuse" value="abuse">
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- <label class="form-check-label" for="le-abuse">Abuse</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.weight_gain_life_events" id="le-illness" value="illness">
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- <label class="form-check-label" for="le-illness">Illness</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.weight_gain_life_events" id="le-travel" value="travel">
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- <label class="form-check-label" for="le-travel">Travel</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.weight_gain_life_events" id="le-injury" value="injury">
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- <label class="form-check-label" for="le-injury">Injury</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.weight_gain_life_events" id="le-nightshift_work"
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- value="nightshift_work">
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- <label class="form-check-label" for="le-nightshift_work">Nightshift Work</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.weight_gain_life_events" id="le-job_change"
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- value="job_change">
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- <label class="form-check-label" for="le-job_change">Job Change</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.weight_gain_life_events" id="le-quitting_smoking"
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- value="quitting_smoking">
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- <label class="form-check-label" for="le-quitting_smoking">Quitting Smoking</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.weight_gain_life_events" id="le-alcohol" value="alcohol">
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- <label class="form-check-label" for="le-alcohol">Alcohol</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.weight_gain_life_events" id="le-drugs" value="drugs">
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- <label class="form-check-label" for="le-drugs">Drugs</label>
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- </div>
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- <div class="d-flex flex-grow-1 align-items-end">
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- <div class="form-check form-check-inline mr-3">
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- <input class="form-check-input" type="checkbox" v-model="data.weight_gain_life_events" id="le-medication"
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- value="medication">
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- <label class="form-check-label" for="le-medication">Medication</label>
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- </div>
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- <div class="d-flex flex-grow-1 align-items-end">
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- <label class="text-nowrap mb-0 mr-3">please list:</label>
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- <input type="text" class="form-control d-inline flex-grow-1" v-model="data.weight_gain_life_events_medication_list" />
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- </div>
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- </div>
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-
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- </div>
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- </div>
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- </div>
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-
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- <div class="col-md-12 section">
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- <div class="form-group">
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- <label>Previous weight-loss programs (check all that apply):</label>
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- <div class="unified-checks flex-basis-20">
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.previous_sleep_study_programs" id="pwl-weight_watchers" value="weight_watchers">
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- <label class="form-check-label" for="pwl-weight_watchers">Weight Watchers</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.previous_sleep_study_programs" id="pwl-nutrisystem" value="nutrisystem">
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- <label class="form-check-label" for="pwl-nutrisystem">Nutrisystem</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.previous_sleep_study_programs" id="pwl-jenny_craig" value="jenny_craig">
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- <label class="form-check-label" for="pwl-jenny_craig">Jenny Craig</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.previous_sleep_study_programs" id="pwl-la_weight_loss" value="la_weight_loss">
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- <label class="form-check-label" for="pwl-la_weight_loss">LA Weight Loss</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.previous_sleep_study_programs" id="pwl-atkins" value="atkins">
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- <label class="form-check-label" for="pwl-atkins">Atkins</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.previous_sleep_study_programs" id="pwl-south_beach" value="south_beach">
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- <label class="form-check-label" for="pwl-south_beach">South Beach</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.previous_sleep_study_programs" id="pwl-zone_diet" value="zone_diet">
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- <label class="form-check-label" for="pwl-zone_diet">Zone diet</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.previous_sleep_study_programs" id="pwl-medifast" value="medifast">
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- <label class="form-check-label" for="pwl-medifast">Medifast</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.previous_sleep_study_programs" id="pwl-dash_diet" value="dash_diet">
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- <label class="form-check-label" for="pwl-dash_diet">Dash Diet</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.previous_sleep_study_programs" id="pwl-paleo_diet" value="paleo_diet">
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- <label class="form-check-label" for="pwl-paleo_diet">Paleo Diet</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.previous_sleep_study_programs" id="pwl-hcg_diet" value="hcg_diet">
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- <label class="form-check-label" for="pwl-hcg_diet">HCG diet</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.previous_sleep_study_programs" id="pwl-mediterranean_diet" value="mediterranean_diet">
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- <label class="form-check-label" for="pwl-mediterranean_diet">Mediterranean diet</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.previous_sleep_study_programs" id="pwl-ornish_diet" value="ornish_diet">
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- <label class="form-check-label" for="pwl-ornish_diet">Ornish diet</label>
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- </div>
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-
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- <div class="d-flex flex-grow-1 align-items-end">
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- <div class="form-check form-check-inline mr-3">
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- <input class="form-check-input" type="checkbox" v-model="data.previous_sleep_study_programs" id="pwl-other"
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- value="other">
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- <label class="form-check-label" for="pwl-other">Other</label>
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- </div>
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- <div class="d-flex flex-grow-1 align-items-end">
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- <label class="text-nowrap mb-0 mr-3">please list:</label>
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- <input type="text" class="form-control d-inline flex-grow-1" v-model="data.previous_sleep_study_programs_others_list" />
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- </div>
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- </div>
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-
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- </div>
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- </div>
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- </div>
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-
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- <div class="col-md-12 section bg-light pt-2 mb-3">
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- <div class="form-group">
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- <div class="d-flex">
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- <label>What was your maximum weight loss?</label>
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- <input type="text" class="form-control inline flex-grow-1" v-model="data.max_weight_loss">
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- </div>
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- <div class="mt-3">
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- <div class="d-flex flex-column">
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- <label>What are your greatest challenges with dieting?</label>
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- <textarea class="form-control inline" v-model="data.greatest_challenge"></textarea>
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- </div>
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- </div>
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- </div>
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- </div>
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-
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- <div class="col-md-12 section">
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- <div class="form-group">
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- <label>Have you ever taken medication to lose weight? (check all that apply):</label>
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- <div class="unified-checks flex-basis-23">
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.sleep_study_medication" id="wlm-phentermine" value="phentermine">
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- <label class="form-check-label" for="wlm-phentermine">Phentermine (Adipex)</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.sleep_study_medication" id="wlm-meridia" value="meridia">
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- <label class="form-check-label" for="wlm-meridia">Meridia</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.sleep_study_medication" id="wlm-xenecal" value="xenecal">
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- <label class="form-check-label" for="wlm-xenecal">Xenecal/Alli</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.sleep_study_medication" id="wlm-phen" value="phen">
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- <label class="form-check-label" for="wlm-phen">Phen/Fen</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.sleep_study_medication" id="wlm-phendimetrazine" value="phendimetrazine">
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- <label class="form-check-label" for="wlm-phendimetrazine">Phendimetrazine(Bontril)</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.sleep_study_medication" id="wlm-topamax" value="topamax">
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- <label class="form-check-label" for="wlm-topamax">Topamax</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.sleep_study_medication" id="wlm-saxenda" value="saxenda">
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- <label class="form-check-label" for="wlm-saxenda">Saxenda</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.sleep_study_medication" id="wlm-diethylpropion" value="diethylpropion">
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- <label class="form-check-label" for="wlm-diethylpropion">Diethylpropion</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.sleep_study_medication" id="wlm-bupropion" value="bupropion">
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- <label class="form-check-label" for="wlm-bupropion">Bupropion (Wellbutrin)</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.sleep_study_medication" id="wlm-belviq" value="belviq">
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- <label class="form-check-label" for="wlm-belviq">Belviq</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.sleep_study_medication" id="wlm-qsymia" value="qsymia">
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- <label class="form-check-label" for="wlm-qsymia">Qsymia</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <input class="form-check-input" type="checkbox" v-model="data.sleep_study_medication" id="wlm-contrave" value="contrave">
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- <label class="form-check-label" for="wlm-contrave">Contrave</label>
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- </div>
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-
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- <div class="d-flex flex-grow-1 align-items-end">
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- <div class="form-check form-check-inline mr-3">
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- <input class="form-check-input" type="checkbox" v-model="data.sleep_study_medication" id="wlm-other"
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- value="other">
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- <label class="form-check-label" for="wlm-other">Other</label>
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- </div>
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- <div class="d-flex flex-grow-1 align-items-end">
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- <label class="text-nowrap mb-0 mr-3">(including supplements):</label>
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- <input type="text" class="form-control d-inline flex-grow-1" v-model="data.sleep_study_medication_other" />
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- </div>
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- </div>
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- </div>
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- <div class="form-group mt-3">
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- <div class="d-flex">
|
|
|
- <label>What worked?</label>
|
|
|
- <input type="text" class="form-control inline flex-grow-1" v-model="data.wlm_what_worked" />
|
|
|
- </div>
|
|
|
- </div>
|
|
|
- <div class="form-group">
|
|
|
- <div class="d-flex">
|
|
|
- <label>What didn't work?</label>
|
|
|
- <input type="text" class="form-control inline flex-grow-1" v-model="data.wlm_what_didnt_work" />
|
|
|
- </div>
|
|
|
- </div>
|
|
|
- <div class="form-group">
|
|
|
- <div class="d-flex">
|
|
|
- <label>Why or why not?</label>
|
|
|
- <input type="text" class="form-control inline flex-grow-1" v-model="data.wlm_why_or_why_not" />
|
|
|
- </div>
|
|
|
- </div>
|
|
|
- </div>
|
|
|
- </div>
|
|
|
-
|
|
|
- <div class="col-md-12">
|
|
|
- <h6 class="my-3"><b><u>Nutritional History</u></b></h6>
|
|
|
- </div>
|
|
|
- <div class="col-md-12 section bg-light pt-2 mb-3">
|
|
|
- <div class="form-group">
|
|
|
- <div class="d-flex flex-wrap">
|
|
|
- <label class="mr-3">How often do you eat breakfast?</label>
|
|
|
- <div class="d-flex mr-3">
|
|
|
- <input type="text" class="form-control inline" v-model="data.breakfast_days_per_week">
|
|
|
- <label>days per week at</label>
|
|
|
- </div>
|
|
|
- <div class="d-flex mr-3">
|
|
|
- <input type="text" class="form-control inline" style="width:50px" v-model="data.breakfast_hour">
|
|
|
- <label>:</label>
|
|
|
- </div>
|
|
|
- <div class="d-flex mr-3">
|
|
|
- <input type="text" class="form-control inline" style="width:50px" v-model="data.breakfast_min">
|
|
|
- <label>a.m</label>
|
|
|
- </div>
|
|
|
- </div>
|
|
|
- </div>
|
|
|
-
|
|
|
- <div class="form-group">
|
|
|
- <div class="d-flex flex-wrap">
|
|
|
- <label class="mr-3">Number of times you eat per day:</label>
|
|
|
- <div class="d-flex mr-3">
|
|
|
- <input type="text" class="form-control inline" v-model="data.no_of_times_you_eat_per_day">
|
|
|
- </div>
|
|
|
- <div class="d-flex mr-3 flex-grow-1">
|
|
|
- <label> What beverages do you drink?</label>
|
|
|
- <input type="text" class="form-control inline flex-grow-1" v-model="data.beverages_you_drink">
|
|
|
- </div>
|
|
|
- </div>
|
|
|
- </div>
|
|
|
-
|
|
|
- <div class="form-group">
|
|
|
- <label>Do you get up at night to eat?</label>
|
|
|
- <div>
|
|
|
- <div class="form-check form-check-inline">
|
|
|
- <input class="form-check-input" type="radio" v-model="data.eats_at_night" id="eats-at-night-yes" value="yes">
|
|
|
- <label class="form-check-label" for="eats-at-night-yes">Yes</label>
|
|
|
- </div>
|
|
|
- <div class="form-check form-check-inline">
|
|
|
- <input class="form-check-input" type="radio" v-model="data.eats_at_night" id="eats-at-night-no" value="no">
|
|
|
- <label class="form-check-label" for="eats-at-night-no">No</label>
|
|
|
- </div>
|
|
|
- </div>
|
|
|
- <div class="d-flex mt-3">
|
|
|
- <label>If so, how often?</label>
|
|
|
- <input type="text" class="form-control inline" v-model="data.eats_at_night_when">
|
|
|
- <label>times</label>
|
|
|
- </div>
|
|
|
- </div>
|
|
|
-
|
|
|
- <div class="form-group">
|
|
|
- <div class="d-flex">
|
|
|
- <label>List any food intolerances/restrictions:</label>
|
|
|
- <input type="text" class="form-control inline flex-grow-1" v-model="data.food_intolerances_list">
|
|
|
- </div>
|
|
|
- </div>
|
|
|
- <div class="form-group">
|
|
|
- <label>Food triggers (check all that apply):</label>
|
|
|
- <div class="unified-checks flex-basis-20">
|
|
|
- <div class="form-check form-check-inline">
|
|
|
- <input class="form-check-input" type="checkbox" v-model="data.food_triggers" id="ft-stress" value="stress">
|
|
|
- <label class="form-check-label" for="ft-stress">Stress</label>
|
|
|
- </div>
|
|
|
- <div class="form-check form-check-inline">
|
|
|
- <input class="form-check-input" type="checkbox" v-model="data.food_triggers" id="ft-boredom" value="boredom">
|
|
|
- <label class="form-check-label" for="ft-boredom">Boredom</label>
|
|
|
- </div>
|
|
|
- <div class="form-check form-check-inline">
|
|
|
- <input class="form-check-input" type="checkbox" v-model="data.food_triggers" id="ft-anger" value="anger">
|
|
|
- <label class="form-check-label" for="ft-anger">Anger</label>
|
|
|
- </div>
|
|
|
- <div class="form-check form-check-inline">
|
|
|
- <input class="form-check-input" type="checkbox" v-model="data.food_triggers" id="ft-insomnia" value="insomnia">
|
|
|
- <label class="form-check-label" for="ft-insomnia">Insomnia</label>
|
|
|
- </div>
|
|
|
- <div class="form-check form-check-inline">
|
|
|
- <input class="form-check-input" type="checkbox" v-model="data.food_triggers" id="ft-seeking_reward" value="seeking_reward">
|
|
|
- <label class="form-check-label" for="ft-seeking_reward">Seeking reward</label>
|
|
|
- </div>
|
|
|
- <div class="form-check form-check-inline">
|
|
|
- <input class="form-check-input" type="checkbox" v-model="data.food_triggers" id="ft-parties" value="parties">
|
|
|
- <label class="form-check-label" for="ft-parties">Parties</label>
|
|
|
- </div>
|
|
|
- <div class="form-check form-check-inline">
|
|
|
- <input class="form-check-input" type="checkbox" v-model="data.food_triggers" id="ft-eating_out" value="eating_out">
|
|
|
- <label class="form-check-label" for="ft-eating_out">Eating out</label>
|
|
|
- </div>
|
|
|
- <div class="d-flex flex-grow-1 align-items-end">
|
|
|
- <div class="form-check form-check-inline mr-3">
|
|
|
- <input class="form-check-input" type="checkbox" v-model="data.food_triggers" id="ft-other"
|
|
|
- value="other">
|
|
|
- <label class="form-check-label" for="ft-other">Other</label>
|
|
|
- </div>
|
|
|
- <div class="d-flex flex-grow-1 align-items-end">
|
|
|
- <input type="text" class="form-control d-inline flex-grow-1" v-model="data.food_triggers_other" />
|
|
|
- </div>
|
|
|
- </div>
|
|
|
- </div>
|
|
|
- </div>
|
|
|
- <div class="form-group">
|
|
|
- <label>Food cravings:</label>
|
|
|
- <div class="unified-checks flex-basis-20">
|
|
|
- <div class="form-check form-check-inline">
|
|
|
- <input class="form-check-input" type="checkbox" v-model="data.food_cravings" id="fc-sugar" value="sugar">
|
|
|
- <label class="form-check-label" for="fc-sugar">Sugar</label>
|
|
|
- </div>
|
|
|
- <div class="form-check form-check-inline">
|
|
|
- <input class="form-check-input" type="checkbox" v-model="data.food_cravings" id="fc-chocolate" value="chocolate">
|
|
|
- <label class="form-check-label" for="fc-chocolate">Chocolate</label>
|
|
|
- </div>
|
|
|
- <div class="form-check form-check-inline">
|
|
|
- <input class="form-check-input" type="checkbox" v-model="data.food_cravings" id="fc-starches" value="starches">
|
|
|
- <label class="form-check-label" for="fc-starches">Starches</label>
|
|
|
- </div>
|
|
|
- <div class="form-check form-check-inline">
|
|
|
- <input class="form-check-input" type="checkbox" v-model="data.food_cravings" id="fc-salty" value="salty">
|
|
|
- <label class="form-check-label" for="fc-salty">Salty</label>
|
|
|
- </div>
|
|
|
- <div class="form-check form-check-inline">
|
|
|
- <input class="form-check-input" type="checkbox" v-model="data.food_cravings" id="fc-fast_food" value="fast_food">
|
|
|
- <label class="form-check-label" for="fc-fast_food">Fast food</label>
|
|
|
- </div>
|
|
|
- <div class="form-check form-check-inline">
|
|
|
- <input class="form-check-input" type="checkbox" v-model="data.food_cravings" id="fc-high_fat" value="high_fat">
|
|
|
- <label class="form-check-label" for="fc-high_fat">High fat</label>
|
|
|
- </div>
|
|
|
- <div class="form-check form-check-inline">
|
|
|
- <input class="form-check-input" type="checkbox" v-model="data.food_cravings" id="fc-largr_portions" value="largr_portions">
|
|
|
- <label class="form-check-label" for="fc-largr_portions">Large portions</label>
|
|
|
- </div>
|
|
|
- <div class="d-flex flex-grow-1 align-items-end">
|
|
|
- <div class="form-check form-check-inline mr-3">
|
|
|
- <input class="form-check-input" type="checkbox" v-model="data.food_cravings" id="fc-other"
|
|
|
- value="other">
|
|
|
- <label class="form-check-label" for="fc-other">Favorite foods</label>
|
|
|
- </div>
|
|
|
- <div class="d-flex flex-grow-1 align-items-end">
|
|
|
- <input type="text" class="form-control d-inline flex-grow-1" v-model="data.food_cravings_favourites" />
|
|
|
- </div>
|
|
|
- </div>
|
|
|
- </div>
|
|
|
- </div>
|
|
|
-
|
|
|
-
|
|
|
- </div>
|
|
|
-
|
|
|
- <div class="col-md-12">
|
|
|
- <h6 class="my-3"><b><u>Exercise & Sleep</u></b></h6>
|
|
|
- </div>
|
|
|
-
|
|
|
- <div class="col-md-12 section bg-light pt-2 mb-3">
|
|
|
- <div class="form-group">
|
|
|
- <div class="d-flex">
|
|
|
- <label>Exercise type:</label>
|
|
|
- <input type="text" class="form-control inline flex-grow-1" v-model="data.medical_history_exercise_type">
|
|
|
- </div>
|
|
|
- </div>
|
|
|
- <div class="form-group">
|
|
|
- <div class="d-flex flex-wrap">
|
|
|
- <label class="mr-3">Duration:</label>
|
|
|
- <div class="d-flex mr-3">
|
|
|
- <input type="text" class="form-control inline" v-model="data.medical_history_hours">
|
|
|
- <label>hours</label>
|
|
|
- </div>
|
|
|
- <div class="d-flex mr-3">
|
|
|
- <input type="text" class="form-control inline" style="width:50px" v-model="data.medical_history_mins">
|
|
|
- <label>minutes</label>
|
|
|
- </div>
|
|
|
- <div class="d-flex mr-3 flex-grow-1">
|
|
|
- <label>Number of times per week:</label>
|
|
|
- <input type="text" class="form-control inline flex-grow-1" v-model="data.medical_history_no_of_times_per_week">
|
|
|
-
|
|
|
- </div>
|
|
|
- </div>
|
|
|
- </div>
|
|
|
- </div>
|
|
|
-
|
|
|
- <div class="col-md-12">
|
|
|
- <div class="form-group">
|
|
|
- <div class="d-flex flex-wrap">
|
|
|
- <label class="mr-3">How many hours do you sleep per night?</label>
|
|
|
- <div class="d-flex mr-3">
|
|
|
- <input type="text" class="form-control inline" v-model="data.sleeping_hours_per_night">
|
|
|
- </div>
|
|
|
- <div class="d-flex mr-3 flex-grow-1">
|
|
|
- <label>Do you feel rested in the morning?</label>
|
|
|
- <input type="text" class="form-control inline flex-grow-1" v-model="data.feels_rested_in_morning">
|
|
|
- </div>
|
|
|
- </div>
|
|
|
- </div>
|
|
|
- </div>
|
|
|
-
|
|
|
- <div class="col-md-12">
|
|
|
- <h6 class="my-3"><b><u>Past medical history (check all that apply)</u></b></h6>
|
|
|
- </div>
|
|
|
- <div class="col-md-12 section bg-light py-2 mb-3">
|
|
|
- <div class="c-pointer"
|
|
|
- open-in-stag-popup
|
|
|
- href="/note-segment-view-by-name/{{$note->uid}}/past_medical_history/edit"
|
|
|
- mc-initer="edit-univ_history_past_medical-container-{{$note->id}}"
|
|
|
- title="Past Medical History"
|
|
|
- update-parent
|
|
|
- popup-style="overflow-visible">
|
|
|
- @include('app.patient.segment-templates.omega_history_past_medical.summary')
|
|
|
- </div>
|
|
|
- </div>
|
|
|
-
|
|
|
- <div class="col-md-12">
|
|
|
- <h6 class="my-3"><b><u>Medications</u></b></h6>
|
|
|
- </div>
|
|
|
- <div class="col-md-12 section bg-light py-2 mb-3">
|
|
|
- <div class="c-pointer"
|
|
|
- open-in-stag-popup
|
|
|
- href="/medications-center/{{$patient->uid}}/{{$note->uid}}"
|
|
|
- mc-initer="medications-center-{{$note->id}}"
|
|
|
- title="Medications Center"
|
|
|
- update-parent
|
|
|
- popup-style="overflow-visible">
|
|
|
- @include('app.patient.segment-templates.omega_medications.active-linear-summary')
|
|
|
- </div>
|
|
|
- </div>
|
|
|
-
|
|
|
- <div class="col-md-12">
|
|
|
- <h6 class="my-3"><b><u>Allergies</u></b></h6>
|
|
|
- </div>
|
|
|
-
|
|
|
- <div class="col-md-12 section bg-light py-2 mb-3">
|
|
|
- <div class="c-pointer"
|
|
|
- open-in-stag-popup
|
|
|
- href="/allergies-center/{{$patient->uid}}/{{$note->uid}}"
|
|
|
- mc-initer="allergies-center-{{$note->id}}"
|
|
|
- title="Allergies Center"
|
|
|
- update-parent
|
|
|
- popup-style="overflow-visible">
|
|
|
- @include('app.patient.segment-templates.omega_allergies.active-linear-summary')
|
|
|
- </div>
|
|
|
- </div>
|
|
|
-
|
|
|
- <div class="col-md-12">
|
|
|
- <h6 class="my-3"><b><u>Social History</u></b></h6>
|
|
|
- </div>
|
|
|
-
|
|
|
- <div class="col-md-12 section bg-light py-2 mb-3">
|
|
|
- <div class="c-pointer"
|
|
|
- open-in-stag-popup
|
|
|
- href="/note-segment-view-by-name/{{$note->uid}}/history_social/edit"
|
|
|
- mc-initer="edit-univ_history_social-container-{{$note->id}}"
|
|
|
- title="Social History"
|
|
|
- popup-style="overflow-visible">
|
|
|
- @include('app.patient.segment-templates.omega_history_social.summary')
|
|
|
- </div>
|
|
|
- </div>
|
|
|
-
|
|
|
- <div class="col-md-12">
|
|
|
- <h6 class="my-3"><b><u>Family History</u></b></h6>
|
|
|
- </div>
|
|
|
-
|
|
|
- <div class="col-md-12 section bg-light py-2 mb-3">
|
|
|
- <div class="c-pointer"
|
|
|
- open-in-stag-popup
|
|
|
- href="/note-segment-view-by-name/{{$note->uid}}/history_family/edit"
|
|
|
- mc-initer="edit-univ_history_family-container-{{$note->id}}"
|
|
|
- title="Family History"
|
|
|
- popup-style="overflow-visible">
|
|
|
- @include('app.patient.segment-templates.omega_history_family.summary')
|
|
|
- </div>
|
|
|
- </div>
|
|
|
-
|
|
|
- <div class="col-md-12">
|
|
|
- <h6 class="my-3"><b><u>Gynecologic History</u></b></h6>
|
|
|
- </div>
|
|
|
-
|
|
|
- <div class="col-md-12 section bg-light pt-2 mb-3">
|
|
|
- <div class="form-group">
|
|
|
- <div class="d-flex flex-wrap">
|
|
|
- <label class="mr-3">Age periods started?</label>
|
|
|
- <div class="d-flex mr-3">
|
|
|
- <input type="text" class="form-control inline" v-model="data.age_periods_started" style="width:50px">
|
|
|
- </div>
|
|
|
- <div class="d-flex mr-3">
|
|
|
- <label>Age periods ended</label>
|
|
|
- <input type="text" class="form-control inline" style="width:50px" v-model="data.age_periods_ended">
|
|
|
- </div>
|
|
|
- </div>
|
|
|
- </div>
|
|
|
- <div class="form-group">
|
|
|
- <label>Periods are:</label>
|
|
|
- <div class="d-flex">
|
|
|
- <div class="mr-5">
|
|
|
- <div class="form-check form-check-inline">
|
|
|
- <input class="form-check-input" type="radio" v-model="data.periods_frequency" id="periods-frequency-regular" value="regular">
|
|
|
- <label class="form-check-label" for="periods-frequency-regular">Regular</label>
|
|
|
- </div>
|
|
|
- <div class="form-check form-check-inline">
|
|
|
- <input class="form-check-input" type="radio" v-model="data.periods_frequency" id="periods-frequency-irregular" value="irregular">
|
|
|
- <label class="form-check-label" for="periods-frequency-irregular">Irregular</label>
|
|
|
- </div>
|
|
|
- </div>
|
|
|
- <div>
|
|
|
- <div class="form-check form-check-inline">
|
|
|
- <input class="form-check-input" type="radio" v-model="data.periods_intensity" id="periods-intensity-heavy" value="heavy">
|
|
|
- <label class="form-check-label" for="periods-intensity-heavy">Heavy</label>
|
|
|
- </div>
|
|
|
- <div class="form-check form-check-inline">
|
|
|
- <input class="form-check-input" type="radio" v-model="data.periods_intensity" id="periods-intensity-normal" value="normal">
|
|
|
- <label class="form-check-label" for="periods-intensity-normal">Normal</label>
|
|
|
- </div>
|
|
|
- <div class="form-check form-check-inline">
|
|
|
- <input class="form-check-input" type="radio" v-model="data.periods_intensity" id="periods-intensity-light" value="light">
|
|
|
- <label class="form-check-label" for="periods-intensity-light">Light</label>
|
|
|
- </div>
|
|
|
- </div>
|
|
|
- </div>
|
|
|
- </div>
|
|
|
- <div class="form-group">
|
|
|
- <div class="d-flex flex-wrap">
|
|
|
- <label class="mr-3">Number of pregnancies:</label>
|
|
|
- <div class="d-flex mr-3">
|
|
|
- <input type="text" class="form-control inline" v-model="data.no_of_pregnancies" style="width:50px">
|
|
|
- </div>
|
|
|
- <div class="d-flex mr-3">
|
|
|
- <label>Number of children:</label>
|
|
|
- <input type="text" class="form-control inline" style="width:50px" v-model="data.no_of_children">
|
|
|
- </div>
|
|
|
- </div>
|
|
|
- </div>
|
|
|
- <div class="form-group">
|
|
|
- <div class="d-flex flex-wrap">
|
|
|
- <label class="mr-3">Age of first pregnancy:</label>
|
|
|
- <div class="d-flex mr-3">
|
|
|
- <input type="text" class="form-control inline" v-model="data.age_of_first_pregnancy" style="width:50px">
|
|
|
- </div>
|
|
|
- <div class="d-flex mr-3">
|
|
|
- <label>Age of last pregnancy:</label>
|
|
|
- <input type="text" class="form-control inline" style="width:50px" v-model="data.age_of_last_pregnancy">
|
|
|
- </div>
|
|
|
- </div>
|
|
|
- </div>
|
|
|
-
|
|
|
-
|
|
|
-
|
|
|
- </div>
|
|
|
-
|
|
|
- <div class="col-md-12">
|
|
|
- <h6 class="my-3"><b><u>System Review</u></b></h6>
|
|
|
- </div>
|
|
|
-
|
|
|
- <div class="col-md-12 section bg-light py-2 mb-3">
|
|
|
- <div class="c-pointer"
|
|
|
- open-in-stag-popup
|
|
|
- href="/note-segment-view-by-name/{{$note->uid}}/omega_ros/edit"
|
|
|
- mc-initer="init-ros-{{$note->id}}"
|
|
|
- title="Review Of Systems"
|
|
|
- popup-style="overflow-visible">
|
|
|
- @include('app.patient.segment-templates.omega_ros.summary')
|
|
|
- </div>
|
|
|
- </div>
|
|
|
-
|
|
|
- <div class="col-md-12">
|
|
|
- <h6 class="my-3"><b><u>(Women only)</u></b></h6>
|
|
|
- </div>
|
|
|
-
|
|
|
- <div class="col-md-12 section bg-light pt-2 mb-3">
|
|
|
- <div class="form-group">
|
|
|
- <div class="unified-checks flex-basis-31">
|
|
|
- <div class="form-check form-check-inline">
|
|
|
- <input class="form-check-input" type="checkbox" v-model="data.women_only" id="wo-periods_absence" value="periods_absence">
|
|
|
- <label class="form-check-label" for="wo-periods_absence">Absence of periods </label>
|
|
|
- </div>
|
|
|
- <div class="form-check form-check-inline">
|
|
|
- <input class="form-check-input" type="checkbox" v-model="data.women_only" id="wo-hot_flashes" value="hot_flashes">
|
|
|
- <label class="form-check-label" for="wo-hot_flashes">Hot flashes</label>
|
|
|
- </div>
|
|
|
- <div class="form-check form-check-inline">
|
|
|
- <input class="form-check-input" type="checkbox" v-model="data.women_only" id="wo-bladder_habits_change" value="bladder_habits_change">
|
|
|
- <label class="form-check-label" for="wo-bladder_habits_change">Change in bladder habits</label>
|
|
|
- </div>
|
|
|
- <div class="form-check form-check-inline">
|
|
|
- <input class="form-check-input" type="checkbox" v-model="data.women_only" id="wo-abnormal_menstruation" value="abnormal_menstruation">
|
|
|
- <label class="form-check-label" for="wo-abnormal_menstruation">Abnormal/excessive menstruation</label>
|
|
|
- </div>
|
|
|
- <div class="form-check form-check-inline">
|
|
|
- <input class="form-check-input" type="checkbox" v-model="data.women_only" id="wo-facial_hair" value="facial_hair">
|
|
|
- <label class="form-check-label" for="wo-facial_hair"> Facial hair</label>
|
|
|
- </div>
|
|
|
-
|
|
|
- </div>
|
|
|
- </div>
|
|
|
- </div>
|
|
|
-
|
|
|
- <div class="col-md-12 section mt-2">
|
|
|
- <div class="form-group">
|
|
|
- <label>Comments:</label>
|
|
|
- <textarea type="text" class="form-control inline flex-grow-1" v-model="data.comments"></textarea>
|
|
|
- </div>
|
|
|
- </div>
|
|
|
-
|
|
|
- <div class="col-md-12">
|
|
|
- <h6 class="my-3"><b><u>Plan</u></b></h6>
|
|
|
- </div>
|
|
|
- <div class="col-md-12 section bg-light pt-2 mb-3">
|
|
|
- <div class="form-group">
|
|
|
- <label>(list all current medications, including over-the-counter medications, supplements, and herbs):</label>
|
|
|
- </div>
|
|
|
- <div class="form-group">
|
|
|
- <label>SMART Goal for Weight Loss:</label>
|
|
|
- <textarea type="text" class="form-control inline flex-grow-1" v-model="data.smart_goal_for_weight_loss"></textarea>
|
|
|
- </div>
|
|
|
- </div>
|
|
|
-
|
|
|
</div>
|
|
|
|
|
|
<div class="mt-3 pt-3 border-top text-center">
|
