A.     Demographics Information

1. Health Card #
2. Chart#

B.      Social History

1. Do you exercise? How often?
2. Do you smoke? How often?
3. Do you drink? How often?
4. Do you take drugs? How often?

C.      Physical Exam Findings

      HT:                                 WT:                        BMI:                      Heart Rate:

D.     Clinical Data (Sub Form)

      Please select if you have ever diagnosed with any of the following conditions:

      1. Thyroid

      2. Arthritis

      3. Lupus

      4. Breast cancer

      5. Ovarian Cancer

      6. Genetic Abnormalities

      7. Sexually Transmitted Diseases (STDs)

      8. Abdominal Pain

      Any medication that are taking for each diagnosis?

      Upload health records

E.      Past Medical History

      Please explain if you had any previous surgery?

      Please explain if you had any medical illnesses or psychiatric conditions?

      Please Mark if you have allergies to any of the following options? Mark all that applies

      Nuts

      Iodine

      Latex

F.      Record of the date and personnel who filled out the form

1.  
   Under a form record, the user might need to enter multiple medical conditions and a corresponding list of medications & health record. In order to do this, the user can create a sub-form.

1.  Click on 'Sub Form' to add a title to this section.
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2. Adding a Dropdown field with the list of values- Health Condition:
   
   To add attributes under this, select the

1. subform from the list on the right. Select 'Drop Down' to add a list of health conditions that the user can select from. When 'Drop down' is selected, user can add values that should appear under 'Permissible values' section.

1.  
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   Note
   For multiple condition values, you can also create a text document or a CSV file with all of the

1. values and upload it rather than entering one by one.

1. Refer to 'How to upload permissible values' section of the wiki page for more details.

   
   

2. Large comments

1. field Medications:
   
   To add a list of medications like a doctor note, click on the sub form and use 'Text Area'

1. control.
   

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2. Upload file

1. field Health Records:
   
   Select

1. subform and click on 'Upload File' to be able to

1. upload any documents for the health record.
   

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1. Box' for adding any explanation of past conditions/procedure.
   

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2. Adding '

1. Multiple Select' field Any Allergies? Mark all that applies: 
   
   Drop down allows to choose only one value, if

1. you want to select multiple values under the same field, 'Multiple Select' control can be used. 
   Select 'Multiple Select' from the attribute bar to add a list of allergic items. This will provide the user with the ability to select multiple options if applicable
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1. Note

1. If a value needs to be made as default, select the appropriate radio button under the list of values.

   
   

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2. Including standard OpenSpecimen fields within custom forms User Dropdown:
   
   Control type 'Fancy Control' helps to include fields already existing in OpenSpecimen. For example, to include list of users, sites, etc. 
   To add personnel, select 'Fancy Control' and select 'User Dropdown' under the fancy control field.
   

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   This will include the list of users automatically created under 'Users' feature of OpenSpecimen.