Patient Demographics and Clinical History Form

A.     Demographics Information

1. Health Card #

2. Chart Number

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 (SubForm)

  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

A. Demographics Information

• Add a note - ‘Demographics Information’ : To add a title to this section, click on 'Note' and fill up the information. 

Open

Open

• Add a number field - ‘Health Card' : To add the field 'Health Card', click on '+ Add Field’ and select 'Number Field'. Fill up the information and click on 'Save'.

• Make fields mandatory and use the ‘Copy' field feature- 'Chart Number’ : To add Chart Number, click on '+ Add Field’ and select 'Number Field'. You can also copy the control you created in the previous step by clicking on the 'Copy' icon.

B. Social History 

• Add a radio button - 'Do you Exercise?' : To add questions for this section, use the Radio Button control as this is a Yes/No question with only two options to select from.

• Add a number field - 'How often do you exercise?' : Use 'Number Field' to add the frequency of each task.

Similarly, add other fields of social history.

C.      Physical Exam Findings

Add HT, WT, BMI & Heart Rate : In order to add measurements for height, weight, BMI, and heart rate, use 'Number Field'.

D.     Clinical Data (SubForm)

• Add subform : Under a form record, you might need to enter multiple medical conditions and a corresponding list of medications and health records. In order to do this, you can create a subform. Click on 'Subform' to add a title to this section.

• Add a dropdown field with the list of values - 'Health Conditions' :

  To add attributes under this, go to the subform. Select 'Dropdown' to add a list of health conditions.

• Large comments field 'Medications’ : To add a list of medications like a doctor note, click on the subform and use 'Text Area' control.

• Upload file field 'Health Record' : Select subform and click on 'File Upload' to be able to upload any documents for the health record.

E.      Past Medical History

• Add more fields to the main form 'Please explain if you had any previous surgery?' : To add sections to the original form, make sure to go back to the main form. Use 'Text Field' for adding any explanation of past conditions/procedures.

• Add checkbox or multiselect dropdown field ‘Any Allergies? Mark all that applies' : Select 'Checkbox' or 'Multiselect Dropdown’ to add a list of allergic items. This will provide the user with the ability to select multiple options if applicable.

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

• Adding a date field 'Date of Submission' : To keep track of the date that a form was submitted, select 'Date Picker' from the list of attributes.

• Including 'User' dropdown : Select 'User' type to add personnel. This will display all the users existing in OpenSpecimen.