\<CPRS_TEMPLATE\>

\<TEMPLATE NAME=\"Preop Surg/Anes History &amp; Physical Template Oct 28
2002\"\>

\<TYPE\>G\</TYPE\>

\<STATUS\>A\</STATUS\>

\<DIALOG\>1\</DIALOG\>

\<HIDE_DIALOG_ITEMS\>1\</HIDE_DIALOG_ITEMS\>

\<HIDE_TREE_ITEMS\>1\</HIDE_TREE_ITEMS\>

\<BOILERPLATE_TEXT\>

\<p\>{FLD:CLICK TO ACTIVATE}\</p\>

\<p\> \</p\>

\<p\>PATIENT AGE: \|PATIENT AGE\| GENDER: \|SEX\|\</p\>

\<p\>PLANNED PROCEDURE (&amp; SIDE): \</p\>

\<p\> {FLD:EDIT BOX50} {FLD:RIGHT/LEFT}\</p\>

\<p\>PLANNED PROCEDURE DATE: {FLD:DATE}\</p\>

\<p\>\</p\>

\<p\>HISTORY:\</p\>

\<p\>\-\-\-\-\-\--\</p\>

\<p\>CHIEF COMPLAINT:\</p\>

\<p\>{FLD:W-PINDENT3}\</p\>

\<p\>HISTORY OF PRESENT ILLNESS:\</p\>

\<p\>{FLD:W-PINDENT3}\</p\>

\<p\>RELEVANT PAST HOSPITALIZATIONS/SURGERIES:\</p\>

\<p\>{FLD:W-PINDENT3}\</p\>

\<p\>RELEVANT PAST AND SOCIAL HISTORY:\</p\>

\<p\> \|RELIGION\|\</p\>

\<p\>{FLD:W-PINDENT3}\</p\>

\<p\>PAST ANESTHETIC PROBLEMS AND PERTINENT FAMILY HISTORY:\</p\>

\<p\>{FLD:W-PINDENT3}\</p\>

\</BOILERPLATE_TEXT\>

\<DESCRIPTION\>

\<p\>10/28/02 MNM\</p\>

\</DESCRIPTION\>

\<ITEMS\>

\<TEMPLATE NAME=\"Cardiovasc\"\>

\<TYPE\>G\</TYPE\>

\<STATUS\>A\</STATUS\>

\<DIALOG\>1\</DIALOG\>

\<HIDE_DIALOG_ITEMS\>1\</HIDE_DIALOG_ITEMS\>

\<INDENT_ITEMS\>1\</INDENT_ITEMS\>

\<BOILERPLATE_TEXT\>

\<p\> CARDIOVASCULAR:\</p\>

\</BOILERPLATE_TEXT\>

\<ITEMS\>

\<TEMPLATE NAME=\"CardioVasc Conditions\"\>

\<TYPE\>G\</TYPE\>

\<STATUS\>A\</STATUS\>

\<DIALOG\>1\</DIALOG\>

\<HIDE_DIALOG_ITEMS\>1\</HIDE_DIALOG_ITEMS\>

\<INDENT_ITEMS\>1\</INDENT_ITEMS\>

\<BOILERPLATE_TEXT\>

\<p\> Cardiovascular Conditions: {FLD:NONE}\</p\>

\</BOILERPLATE_TEXT\>

\<ITEMS\>

\<TEMPLATE NAME=\"Angina\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Angina within past 1 month\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"AMI\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> MI within past 6 month\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"CHF\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> CHF within past 1 month\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Valv\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Valvular disease\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"PTCA\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Previous PTCA\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"CPB\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Previous operation with CPB\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"AICD\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Pacemaker/AICD\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Revasc\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Revascularization/amputation for PVD\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Leg\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Leg rest pain/gangrene\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Pulses\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Absent peripheral pulses\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"HTN\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Hypertension requiring meds\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Studies\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Cardiac Studies (Other than ECG):\</p\>

\<p\>{FLD:W-PINDENT7}\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\</ITEMS\>

\</TEMPLATE\>

\</ITEMS\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Pulmonary\"\>

\<TYPE\>G\</TYPE\>

\<STATUS\>A\</STATUS\>

\<DIALOG\>1\</DIALOG\>

\<HIDE_DIALOG_ITEMS\>1\</HIDE_DIALOG_ITEMS\>

\<INDENT_ITEMS\>1\</INDENT_ITEMS\>

\<BOILERPLATE_TEXT\>

\<p\> PULMONARY:\</p\>

\</BOILERPLATE_TEXT\>

\<ITEMS\>

\<TEMPLATE NAME=\"Pulmonary Conditions\"\>

\<TYPE\>G\</TYPE\>

\<STATUS\>A\</STATUS\>

\<DIALOG\>1\</DIALOG\>

\<HIDE_DIALOG_ITEMS\>1\</HIDE_DIALOG_ITEMS\>

\<INDENT_ITEMS\>1\</INDENT_ITEMS\>

\<BOILERPLATE_TEXT\>

\<p\> Pulmonary Conditions: {FLD:NONE}\</p\>

\</BOILERPLATE_TEXT\>

\<ITEMS\>

\<TEMPLATE NAME=\"Cig\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Cigarette smoker within last 1 year, pack-years: {FLD:EDIT
BOX5}\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"COPD\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> History of severe COPD\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Dysp exertion\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Dyspneic with minimal exertion\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Dysp rest\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Dyspneic at rest\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Pneum\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Current pneumonia\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Asthma\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Asthma\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Co2\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> CO2 Retainer\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Steroid\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Steroid Dependent\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Home O2\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Home 02\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Ventil Dep\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Ventilator Dependent &gt; 48 hrs\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Sleep Apnea\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Sleep Apnea\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Pulm HTN\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Pulmonary hypertension\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Pulm studies\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> PFT Results: \</p\>

\<p\>{FLD:W-PINDENT7}\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\</ITEMS\>

\</TEMPLATE\>

\</ITEMS\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Neurologic\"\>

\<TYPE\>G\</TYPE\>

\<STATUS\>A\</STATUS\>

\<DIALOG\>1\</DIALOG\>

\<HIDE_DIALOG_ITEMS\>1\</HIDE_DIALOG_ITEMS\>

\<INDENT_ITEMS\>1\</INDENT_ITEMS\>

\<BOILERPLATE_TEXT\>

\<p\> NEUROLOGIC:\</p\>

\</BOILERPLATE_TEXT\>

\<ITEMS\>

\<TEMPLATE NAME=\"Neuro conditions\"\>

\<TYPE\>G\</TYPE\>

\<STATUS\>A\</STATUS\>

\<DIALOG\>1\</DIALOG\>

\<HIDE_DIALOG_ITEMS\>1\</HIDE_DIALOG_ITEMS\>

\<INDENT_ITEMS\>1\</INDENT_ITEMS\>

\<BOILERPLATE_TEXT\>

\<p\> Neurologic conditions:{FLD:NONE}\</p\>

\</BOILERPLATE_TEXT\>

\<ITEMS\>

\<TEMPLATE NAME=\"Impaired sens\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Impaired sensorium\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Head\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Severe head trauma\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Coma\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Coma\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Quadriplegia\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Quadriplegia\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Para\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Paraplegia\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Hemi\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Hemiplegia\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"TIA\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> (TIA) Transient Ischemic Attack (deficit &lt; 30 min)\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"CVA\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> CVA without current neuro deficit (deficit &gt; 30 min but
resolved)\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Degen\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Neuromuscular degenerative disease\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Tumor\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Tumor involving CNS\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Seizure\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Seizure disorder\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Studies\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Neuro studies:\</p\>

\<p\>{FLD:W-PINDENT7}\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\</ITEMS\>

\</TEMPLATE\>

\</ITEMS\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Other\"\>

\<TYPE\>G\</TYPE\>

\<STATUS\>A\</STATUS\>

\<DIALOG\>1\</DIALOG\>

\<HIDE_DIALOG_ITEMS\>1\</HIDE_DIALOG_ITEMS\>

\<INDENT_ITEMS\>1\</INDENT_ITEMS\>

\<BOILERPLATE_TEXT\>

\<p\> OTHER SYSTEMS:\</p\>

\</BOILERPLATE_TEXT\>

\<ITEMS\>

\<TEMPLATE NAME=\"Adv Care Dir\"\>

\<TYPE\>G\</TYPE\>

\<STATUS\>A\</STATUS\>

\<DIALOG\>1\</DIALOG\>

\<HIDE_DIALOG_ITEMS\>1\</HIDE_DIALOG_ITEMS\>

\<INDENT_ITEMS\>1\</INDENT_ITEMS\>

\<BOILERPLATE_TEXT\>

\<p\> ADVANCE CARE DIRECTIVES:\</p\>

\</BOILERPLATE_TEXT\>

\<ITEMS\>

\<TEMPLATE NAME=\"on chart\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Advance Care Directives on chart\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"DNAR\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> DNAR orders within 30 days prior to surgery\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\</ITEMS\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Hepatic\"\>

\<TYPE\>G\</TYPE\>

\<STATUS\>A\</STATUS\>

\<DIALOG\>1\</DIALOG\>

\<HIDE_DIALOG_ITEMS\>1\</HIDE_DIALOG_ITEMS\>

\<INDENT_ITEMS\>1\</INDENT_ITEMS\>

\<BOILERPLATE_TEXT\>

\<p\> Hepatic Disease\</p\>

\</BOILERPLATE_TEXT\>

\<ITEMS\>

\<TEMPLATE NAME=\"Hepatom\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Hepatomegaly\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Esoph\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Esophageal varices\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Hepatitis\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Active hepatitis\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Ascites\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Ascites\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\</ITEMS\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Renal\"\>

\<TYPE\>G\</TYPE\>

\<STATUS\>A\</STATUS\>

\<DIALOG\>1\</DIALOG\>

\<HIDE_DIALOG_ITEMS\>1\</HIDE_DIALOG_ITEMS\>

\<INDENT_ITEMS\>1\</INDENT_ITEMS\>

\<BOILERPLATE_TEXT\>

\<p\> Renal Disease\</p\>

\</BOILERPLATE_TEXT\>

\<ITEMS\>

\<TEMPLATE NAME=\"ARF\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Acute Renal Failure\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Dialysis\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Currently on dialysis\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\</ITEMS\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Diabetes\"\>

\<TYPE\>G\</TYPE\>

\<STATUS\>A\</STATUS\>

\<DIALOG\>1\</DIALOG\>

\<HIDE_DIALOG_ITEMS\>1\</HIDE_DIALOG_ITEMS\>

\<INDENT_ITEMS\>1\</INDENT_ITEMS\>

\<BOILERPLATE_TEXT\>

\<p\> Diabetes\</p\>

\</BOILERPLATE_TEXT\>

\<ITEMS\>

\<TEMPLATE NAME=\"Metformin\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Metformin\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Other\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Other oral hypoglycemic\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Insulin\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Insulin\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\</ITEMS\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Other Risk Factors:\"\>

\<TYPE\>G\</TYPE\>

\<STATUS\>A\</STATUS\>

\<DIALOG\>1\</DIALOG\>

\<HIDE_DIALOG_ITEMS\>1\</HIDE_DIALOG_ITEMS\>

\<INDENT_ITEMS\>1\</INDENT_ITEMS\>

\<BOILERPLATE_TEXT\>

\<p\>Other Risk Factors:\</p\>

\</BOILERPLATE_TEXT\>

\<ITEMS\>

\<TEMPLATE NAME=\"ETOH\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> ETOH\--more than 2 drinks per day within the last 2 weeks\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Drug abuse\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Drug abuse\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"GE reflux\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> GE reflux\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Nausea\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Nausea\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Vomiting\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Vomiting\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Chewing\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Difficulty chewing\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Swallowing\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Difficulty swallowing\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Diet\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Modified diet: {FLD:EDIT BOX40}\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Wt loss\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> 10% weight loss last 6 months of 5% in one month\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Dissem CA\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Disseminated cancer\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Chemo\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Chemotherapy for malignancy within 30 days\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Radio\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Radiotherapy for malignancy within 90 days\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Bleeding\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Bleeding disorder\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Transf\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Transfusion &gt; 4 RBC this admission\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Oper\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Number of operations this admission: {FLD:EDIT BOX10}\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Wound\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Open wound\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Sepsis\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Preoperative sepsis\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Steroid\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\>Chronic steroid use\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\</ITEMS\>

\</TEMPLATE\>

\</ITEMS\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Func status\"\>

\<TYPE\>G\</TYPE\>

\<STATUS\>A\</STATUS\>

\<DIALOG\>1\</DIALOG\>

\<ONE_ITEM_ONLY\>1\</ONE_ITEM_ONLY\>

\<HIDE_DIALOG_ITEMS\>1\</HIDE_DIALOG_ITEMS\>

\<INDENT_ITEMS\>1\</INDENT_ITEMS\>

\<BOILERPLATE_TEXT\>

\<p\> FUNCTIONAL STATUS: {FLD:FUNC STATUS2}\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Meds\"\>

\<TYPE\>G\</TYPE\>

\<STATUS\>A\</STATUS\>

\<DIALOG\>1\</DIALOG\>

\<HIDE_DIALOG_ITEMS\>1\</HIDE_DIALOG_ITEMS\>

\<INDENT_ITEMS\>1\</INDENT_ITEMS\>

\<BOILERPLATE_TEXT\>

\<p\>MEDICATION HISTORY:\</p\>

\<p\>\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-- \</p\>

\<p\>ALLERGIES/ADVERSE REACTIONS (as found in the VISTA database):
\|ADR\|\</p\>

\<p\>\</p\>

\<p\>MEDICATIONS (as found in the VISTA database): \|AMED\|\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Phys Exam\"\>

\<TYPE\>G\</TYPE\>

\<STATUS\>A\</STATUS\>

\<DIALOG\>1\</DIALOG\>

\<HIDE_DIALOG_ITEMS\>1\</HIDE_DIALOG_ITEMS\>

\<INDENT_ITEMS\>1\</INDENT_ITEMS\>

\<BOILERPLATE_TEXT\>

\<p\>PHYSICAL EXAMINATION:\</p\>

\<p\>\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--\</p\>

\<p\>HEIGHT: \|HT\| \</p\>

\<p\>WEIGHT: \|WT\|\</p\>

\<p\>TEMPERATURE: \|TEMPERATURE\| \</p\>

\<p\>PULSE: \|PULSE\|\</p\>

\<p\>BP: \|BP\|\</p\>

\<p\>PAIN: \|PAIN\|\</p\>

\<p\>\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Gen Appearance\"\>

\<TYPE\>G\</TYPE\>

\<STATUS\>A\</STATUS\>

\<DIALOG\>1\</DIALOG\>

\<HIDE_DIALOG_ITEMS\>1\</HIDE_DIALOG_ITEMS\>

\<INDENT_ITEMS\>1\</INDENT_ITEMS\>

\<BOILERPLATE_TEXT\>

\<p\>GENERAL APPEARANCE AND MENTAL STATUS:\</p\>

\</BOILERPLATE_TEXT\>

\<ITEMS\>

\<TEMPLATE NAME=\"Head\"\>

\<TYPE\>G\</TYPE\>

\<STATUS\>A\</STATUS\>

\<DIALOG\>1\</DIALOG\>

\<ONE_ITEM_ONLY\>1\</ONE_ITEM_ONLY\>

\<HIDE_DIALOG_ITEMS\>1\</HIDE_DIALOG_ITEMS\>

\<INDENT_ITEMS\>1\</INDENT_ITEMS\>

\<BOILERPLATE_TEXT\>

\<p\> HEAD/NECK:\</p\>

\</BOILERPLATE_TEXT\>

\<ITEMS\>

\<TEMPLATE NAME=\"Normal\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Normal\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Not normal\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Relevant findings\</p\>

\<p\>{FLD:W-PINDENT7}\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\</ITEMS\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Airway\"\>

\<TYPE\>G\</TYPE\>

\<STATUS\>A\</STATUS\>

\<DIALOG\>1\</DIALOG\>

\<ONE_ITEM_ONLY\>1\</ONE_ITEM_ONLY\>

\<HIDE_DIALOG_ITEMS\>1\</HIDE_DIALOG_ITEMS\>

\<INDENT_ITEMS\>1\</INDENT_ITEMS\>

\<BOILERPLATE_TEXT\>

\<p\> AIRWAY:\</p\>

\</BOILERPLATE_TEXT\>

\<ITEMS\>

\<TEMPLATE NAME=\"Normal\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Normal\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Not normal\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Relevant findings\</p\>

\<p\>{FLD:W-PINDENT7}\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\</ITEMS\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Cardiac\"\>

\<TYPE\>G\</TYPE\>

\<STATUS\>A\</STATUS\>

\<DIALOG\>1\</DIALOG\>

\<ONE_ITEM_ONLY\>1\</ONE_ITEM_ONLY\>

\<HIDE_DIALOG_ITEMS\>1\</HIDE_DIALOG_ITEMS\>

\<INDENT_ITEMS\>1\</INDENT_ITEMS\>

\<BOILERPLATE_TEXT\>

\<p\> CARDIAC:\</p\>

\</BOILERPLATE_TEXT\>

\<ITEMS\>

\<TEMPLATE NAME=\"Normal\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Normal\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Not normal\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Relevant findings\</p\>

\<p\>{FLD:W-PINDENT7}\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\</ITEMS\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Lungs\"\>

\<TYPE\>G\</TYPE\>

\<STATUS\>A\</STATUS\>

\<DIALOG\>1\</DIALOG\>

\<ONE_ITEM_ONLY\>1\</ONE_ITEM_ONLY\>

\<HIDE_DIALOG_ITEMS\>1\</HIDE_DIALOG_ITEMS\>

\<INDENT_ITEMS\>1\</INDENT_ITEMS\>

\<BOILERPLATE_TEXT\>

\<p\> LUNGS:\</p\>

\</BOILERPLATE_TEXT\>

\<ITEMS\>

\<TEMPLATE NAME=\"Normal\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Normal\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Not normal\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Relevant findings\</p\>

\<p\>{FLD:W-PINDENT7}\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\</ITEMS\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Abdomen\"\>

\<TYPE\>G\</TYPE\>

\<STATUS\>A\</STATUS\>

\<DIALOG\>1\</DIALOG\>

\<ONE_ITEM_ONLY\>1\</ONE_ITEM_ONLY\>

\<HIDE_DIALOG_ITEMS\>1\</HIDE_DIALOG_ITEMS\>

\<INDENT_ITEMS\>1\</INDENT_ITEMS\>

\<BOILERPLATE_TEXT\>

\<p\> ABDOMEN:\</p\>

\</BOILERPLATE_TEXT\>

\<ITEMS\>

\<TEMPLATE NAME=\"Normal\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Normal\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Not normal\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Relevant findings\</p\>

\<p\>{FLD:W-PINDENT7}\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\</ITEMS\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Extrem\"\>

\<TYPE\>G\</TYPE\>

\<STATUS\>A\</STATUS\>

\<DIALOG\>1\</DIALOG\>

\<ONE_ITEM_ONLY\>1\</ONE_ITEM_ONLY\>

\<HIDE_DIALOG_ITEMS\>1\</HIDE_DIALOG_ITEMS\>

\<INDENT_ITEMS\>1\</INDENT_ITEMS\>

\<BOILERPLATE_TEXT\>

\<p\> EXTREMITIES:\</p\>

\</BOILERPLATE_TEXT\>

\<ITEMS\>

\<TEMPLATE NAME=\"Normal\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Normal\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Not normal\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Relevant findings\</p\>

\<p\>{FLD:W-PINDENT7}\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\</ITEMS\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Neuro\"\>

\<TYPE\>G\</TYPE\>

\<STATUS\>A\</STATUS\>

\<DIALOG\>1\</DIALOG\>

\<ONE_ITEM_ONLY\>1\</ONE_ITEM_ONLY\>

\<HIDE_DIALOG_ITEMS\>1\</HIDE_DIALOG_ITEMS\>

\<INDENT_ITEMS\>1\</INDENT_ITEMS\>

\<BOILERPLATE_TEXT\>

\<p\> NEURO:\</p\>

\</BOILERPLATE_TEXT\>

\<ITEMS\>

\<TEMPLATE NAME=\"Normal\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Normal\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Not normal\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\> Relevant findings\</p\>

\<p\>{FLD:W-PINDENT7}\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\</ITEMS\>

\</TEMPLATE\>

\</ITEMS\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Labs\"\>

\<TYPE\>G\</TYPE\>

\<STATUS\>A\</STATUS\>

\<DIALOG\>1\</DIALOG\>

\<HIDE_DIALOG_ITEMS\>1\</HIDE_DIALOG_ITEMS\>

\<INDENT_ITEMS\>1\</INDENT_ITEMS\>

\<BOILERPLATE_TEXT\>

\<p\>LABS &amp; STUDIES:\</p\>

\<p\>\-\-\-\-\-\-\-\-\-\-\-\-\-\--\</p\>

\<p\>Hct: \|HCT\|\</p\>

\<p\>WBC: \|WBC\|\</p\>

\<p\>Platelets: \|PLT\|\</p\>

\<p\>PT: \|PRO TIME\|\</p\>

\<p\>PTT: \|PTT\|\</p\>

\<p\>INR: \|INR\|\</p\>

\<p\>Na: \|SODIUM\|\</p\>

\<p\>Cl: \|CHLORIDE\|\</p\>

\<p\>CR: \|CREATININE\|\</p\>

\<p\>BUN: \|BUN\|\</p\>

\<p\>Glucose: \|GLUC\|\</p\>

\<p\>K: \|POTASSIUM\|\</p\>

\<p\>HCO3: \|HCO3\|\</p\>

\<p\>CO2: \|CO2\|\</p\>

\<p\>ECG: {FLD:EDIT BOX40} Date: {FLD:DATE}\</p\>

\<p\>CXR: {FLD:EDIT BOX40} Date: {FLD:DATE}\</p\>

\</BOILERPLATE_TEXT\>

\<ITEMS\>

\<TEMPLATE NAME=\"Other1\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\>{FLD:OTHER}{FLD:EDIT BOX40} Date: {FLD:DATE}\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Other2\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\>{FLD:OTHER}{FLD:EDIT BOX40} Date: {FLD:DATE}\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\</ITEMS\>

\</TEMPLATE\>

\<TEMPLATE NAME=\"Assess-Plan\"\>

\<TYPE\>T\</TYPE\>

\<STATUS\>A\</STATUS\>

\<BOILERPLATE_TEXT\>

\<p\>ASSESSMENT/PLAN:\</p\>

\<p\>\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--\</p\>

\<p\>{FLD:VA\*WP-4LINDENT2}\</p\>

\<p\>\|ACTIVE PROBLEMS W/O COMMENTS\|\</p\>

\<p\>Additional Problems:\</p\>

\<p\>{FLD:W-PINDENT3}\</p\>

\</BOILERPLATE_TEXT\>

\</TEMPLATE\>

\</ITEMS\>

\</TEMPLATE\>

\<TEMPLATE_FIELDS\>

\<FIELD NAME=\"CLICK TO ACTIVATE\"\>

\<TYPE\>T\</TYPE\>

\<INACTIVE\>0\</INACTIVE\>

\<LENGTH\>0\</LENGTH\>

\<DEFAULT_INDEX\>0\</DEFAULT_INDEX\>

\<REQUIRED\>0\</REQUIRED\>

\<SEPARATE_LINES\>1\</SEPARATE_LINES\>

\<MAX_LENGTH\>0\</MAX_LENGTH\>

\<INDENT\>0\</INDENT\>

\<PAD\>0\</PAD\>

\<MIN_VALUE\>0\</MIN_VALUE\>

\<MAX_VALUE\>0\</MAX_VALUE\>

\<INCREMENT\>0\</INCREMENT\>

\<DESCRIPTION\>

\<p\>9/14/01 MNM\</p\>

\</DESCRIPTION\>

\<ITEMS\>

\<p\>(Click to activate)\</p\>

\</ITEMS\>

\</FIELD\>

\<FIELD NAME=\"EDIT BOX50\"\>

\<TYPE\>E\</TYPE\>

\<INACTIVE\>0\</INACTIVE\>

\<LENGTH\>50\</LENGTH\>

\<DEFAULT_INDEX\>0\</DEFAULT_INDEX\>

\<REQUIRED\>0\</REQUIRED\>

\<SEPARATE_LINES\>0\</SEPARATE_LINES\>

\<MAX_LENGTH\>50\</MAX_LENGTH\>

\<INDENT\>0\</INDENT\>

\<PAD\>0\</PAD\>

\<MIN_VALUE\>0\</MIN_VALUE\>

\<MAX_VALUE\>0\</MAX_VALUE\>

\<INCREMENT\>0\</INCREMENT\>

\</FIELD\>

\<FIELD NAME=\"RIGHT/LEFT\"\>

\<TYPE\>R\</TYPE\>

\<INACTIVE\>0\</INACTIVE\>

\<LENGTH\>0\</LENGTH\>

\<DEFAULT_INDEX\>0\</DEFAULT_INDEX\>

\<REQUIRED\>0\</REQUIRED\>

\<ITEMS\>

\<p\>Right\</p\>

\<p\>Left\</p\>

\</ITEMS\>

\</FIELD\>

\<FIELD NAME=\"DATE\"\>

\<TYPE\>D\</TYPE\>

\<INACTIVE\>0\</INACTIVE\>

\<LENGTH\>0\</LENGTH\>

\<DEFAULT_INDEX\>0\</DEFAULT_INDEX\>

\<REQUIRED\>0\</REQUIRED\>

\<SEPARATE_LINES\>0\</SEPARATE_LINES\>

\<MAX_LENGTH\>0\</MAX_LENGTH\>

\<INDENT\>0\</INDENT\>

\<PAD\>0\</PAD\>

\<MIN_VALUE\>0\</MIN_VALUE\>

\<MAX_VALUE\>0\</MAX_VALUE\>

\<INCREMENT\>0\</INCREMENT\>

\<DATE_TYPE\>D\</DATE_TYPE\>

\</FIELD\>

\<FIELD NAME=\"W-PINDENT3\"\>

\<TYPE\>W\</TYPE\>

\<INACTIVE\>0\</INACTIVE\>

\<LENGTH\>70\</LENGTH\>

\<DEFAULT_INDEX\>0\</DEFAULT_INDEX\>

\<REQUIRED\>0\</REQUIRED\>

\<SEPARATE_LINES\>0\</SEPARATE_LINES\>

\<MAX_LENGTH\>2\</MAX_LENGTH\>

\<INDENT\>2\</INDENT\>

\<PAD\>2\</PAD\>

\<MIN_VALUE\>0\</MIN_VALUE\>

\<MAX_VALUE\>0\</MAX_VALUE\>

\<INCREMENT\>0\</INCREMENT\>

\<DESCRIPTION\>

\<p\>8/27/01 MNM\</p\>

\</DESCRIPTION\>

\</FIELD\>

\<FIELD NAME=\"NONE\"\>

\<TYPE\>R\</TYPE\>

\<INACTIVE\>0\</INACTIVE\>

\<LENGTH\>0\</LENGTH\>

\<DEFAULT_INDEX\>0\</DEFAULT_INDEX\>

\<REQUIRED\>0\</REQUIRED\>

\<SEPARATE_LINES\>0\</SEPARATE_LINES\>

\<MAX_LENGTH\>0\</MAX_LENGTH\>

\<INDENT\>0\</INDENT\>

\<PAD\>0\</PAD\>

\<MIN_VALUE\>0\</MIN_VALUE\>

\<MAX_VALUE\>0\</MAX_VALUE\>

\<INCREMENT\>0\</INCREMENT\>

\<DESCRIPTION\>

\<p\>6/9/02 MNM\</p\>

\</DESCRIPTION\>

\<ITEMS\>

\<p\>None\</p\>

\</ITEMS\>

\</FIELD\>

\<FIELD NAME=\"W-PINDENT7\"\>

\<TYPE\>W\</TYPE\>

\<INACTIVE\>0\</INACTIVE\>

\<LENGTH\>66\</LENGTH\>

\<DEFAULT_INDEX\>0\</DEFAULT_INDEX\>

\<REQUIRED\>0\</REQUIRED\>

\<SEPARATE_LINES\>0\</SEPARATE_LINES\>

\<MAX_LENGTH\>2\</MAX_LENGTH\>

\<INDENT\>6\</INDENT\>

\<PAD\>6\</PAD\>

\<MIN_VALUE\>0\</MIN_VALUE\>

\<MAX_VALUE\>0\</MAX_VALUE\>

\<INCREMENT\>0\</INCREMENT\>

\<DESCRIPTION\>

\<p\>8/27/01 MNM\</p\>

\</DESCRIPTION\>

\</FIELD\>

\<FIELD NAME=\"EDIT BOX5\"\>

\<TYPE\>E\</TYPE\>

\<INACTIVE\>0\</INACTIVE\>

\<LENGTH\>5\</LENGTH\>

\<DEFAULT_INDEX\>0\</DEFAULT_INDEX\>

\<REQUIRED\>0\</REQUIRED\>

\</FIELD\>

\<FIELD NAME=\"EDIT BOX40\"\>

\<TYPE\>E\</TYPE\>

\<INACTIVE\>0\</INACTIVE\>

\<LENGTH\>40\</LENGTH\>

\<DEFAULT_INDEX\>0\</DEFAULT_INDEX\>

\<REQUIRED\>0\</REQUIRED\>

\</FIELD\>

\<FIELD NAME=\"EDIT BOX10\"\>

\<TYPE\>E\</TYPE\>

\<INACTIVE\>0\</INACTIVE\>

\<LENGTH\>10\</LENGTH\>

\<DEFAULT_INDEX\>0\</DEFAULT_INDEX\>

\<REQUIRED\>0\</REQUIRED\>

\<SEPARATE_LINES\>0\</SEPARATE_LINES\>

\</FIELD\>

\<FIELD NAME=\"FUNC STATUS2\"\>

\<TYPE\>R\</TYPE\>

\<INACTIVE\>0\</INACTIVE\>

\<LENGTH\>0\</LENGTH\>

\<DEFAULT_INDEX\>0\</DEFAULT_INDEX\>

\<REQUIRED\>0\</REQUIRED\>

\<SEPARATE_LINES\>1\</SEPARATE_LINES\>

\<MAX_LENGTH\>0\</MAX_LENGTH\>

\<INDENT\>4\</INDENT\>

\<PAD\>0\</PAD\>

\<MIN_VALUE\>0\</MIN_VALUE\>

\<MAX_VALUE\>0\</MAX_VALUE\>

\<INCREMENT\>0\</INCREMENT\>

\<DESCRIPTION\>

\<p\>6/10/01 MNM\</p\>

\</DESCRIPTION\>

\<ITEMS\>

\<p\>Independent\</p\>

\<p\>Partially dependent\</p\>

\<p\>Totally dependent\</p\>

\</ITEMS\>

\</FIELD\>

\<FIELD NAME=\"OTHER\"\>

\<TYPE\>T\</TYPE\>

\<INACTIVE\>0\</INACTIVE\>

\<LENGTH\>0\</LENGTH\>

\<DEFAULT_INDEX\>0\</DEFAULT_INDEX\>

\<REQUIRED\>0\</REQUIRED\>

\<SEPARATE_LINES\>1\</SEPARATE_LINES\>

\<MAX_LENGTH\>0\</MAX_LENGTH\>

\<INDENT\>0\</INDENT\>

\<PAD\>0\</PAD\>

\<MIN_VALUE\>0\</MIN_VALUE\>

\<MAX_VALUE\>0\</MAX_VALUE\>

\<INCREMENT\>0\</INCREMENT\>

\<DESCRIPTION\>

\<p\>1/4/02 MNM\</p\>

\</DESCRIPTION\>

\<ITEMS\>

\<p\>(other)\</p\>

\</ITEMS\>

\</FIELD\>

\<FIELD NAME=\"VA\*WP-4LINDENT2\"\>

\<TYPE\>W\</TYPE\>

\<INACTIVE\>0\</INACTIVE\>

\<LENGTH\>68\</LENGTH\>

\<DEFAULT_INDEX\>0\</DEFAULT_INDEX\>

\<REQUIRED\>0\</REQUIRED\>

\<SEPARATE_LINES\>0\</SEPARATE_LINES\>

\<MAX_LENGTH\>4\</MAX_LENGTH\>

\<INDENT\>2\</INDENT\>

\<PAD\>2\</PAD\>

\<MIN_VALUE\>0\</MIN_VALUE\>

\<MAX_VALUE\>0\</MAX_VALUE\>

\<INCREMENT\>0\</INCREMENT\>

\<DESCRIPTION\>

\<p\>Created 1-18-02 for initial testing by Natl.\</p\>

\<p\>VA Template Workgroup (Primary Care subgroup)\</p\>

\</DESCRIPTION\>

\</FIELD\>

\</TEMPLATE_FIELDS\>

\</CPRS_TEMPLATE\>