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Medication allergy Reported
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Hx of Severe bleeding due to aspirin use
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Willing to change aspirin dose:Find:Pt:^Patient:Ord:
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Anticoagulant med used
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Pregnancy status
?
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Breastfeeding status
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Health self assess
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Are you able to run errands and shop:Find:Pt:^Patient:Ord:PROMIS
©
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I felt depressed in past 7D:Find:7D:^Patient:Ord:PROMIS
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I feel fatigued during the past 7D:Find:7D:^Patient:Ord:PROMIS
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I had a problem with my sleep 7D:Find:7D:^Patient:Ord:PROMIS
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I have trouble doing all of my regular leisure activities with others in the past 7D:Find:7D:^Patient:Ord:ADAPTABLE
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How much did pain interfere with your day to day activities in past 7D:Find:7D:^Patient:Ord:PROMIS
©
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Satisfaction with using ADAPTABLE web site:Find:Pt:^Patient:Ord:ADAPTABLE
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Adequacy of information on+time spent reading ADAPTABLE web site:Find:Pt:^Patient:Ord:ADAPTABLE
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Patient name
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Sex
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Birth date
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{mm/dd/yyyy}
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