Pre-Visit Intake

Demographics, goals, CC, timeline, PMH/PSH, allergies, immunizations, family history, current Rx/supplements.

Lifestyle baseline: nutrition, hydration, movement, sleep, stress, environment, social context, and readiness.

Display: Working diagnosis / clinical impression

Block Type: medication-list
Block ID: 6527f844-1124-4639-bf76-e6ca29897c30
Schema Version: 1

Medications: Item 1

Status

active

Variant

adult

Content version

ifm-msq-71-v1

Item Responses

Item 1

Label: Headaches
Item ID: head-1
Category ID: head
Category Label: Head

Item 2

Label: Faintness
Item ID: head-2
Category ID: head
Category Label: Head

Item 3

Label: Dizziness
Item ID: head-3
Category ID: head
Category Label: Head

Item 4

Label: Insomnia
Item ID: head-4
Category ID: head
Category Label: Head

Item 5

Label: Watery or itchy eyes
Item ID: eyes-1
Category ID: eyes
Category Label: Eyes

Item 6

Label: Swollen, reddened or sticky eyelids
Item ID: eyes-2
Category ID: eyes
Category Label: Eyes

Item 7

Label: Bags or dark circles under eyes
Item ID: eyes-3
Category ID: eyes
Category Label: Eyes

Item 8

Label: Blurred or tunnel vision
Item ID: eyes-4
Category ID: eyes
Category Label: Eyes

Item 9

Label: Itchy ears
Item ID: ears-1
Category ID: ears
Category Label: Ears

Item 10

Label: Earaches, ear infections
Item ID: ears-2
Category ID: ears
Category Label: Ears

Item 11

Label: Drainage from ear
Item ID: ears-3
Category ID: ears
Category Label: Ears

Item 12

Label: Ringing in ears, hearing loss
Item ID: ears-4
Category ID: ears
Category Label: Ears

Item 13

Label: Stuffy nose
Item ID: nose-1
Category ID: nose
Category Label: Nose

Item 14

Label: Sinus problems
Item ID: nose-2
Category ID: nose
Category Label: Nose

Item 15

Label: Hay fever
Item ID: nose-3
Category ID: nose
Category Label: Nose

Item 16

Label: Sneezing attacks
Item ID: nose-4
Category ID: nose
Category Label: Nose

Item 17

Label: Excessive mucus formation
Item ID: nose-5
Category ID: nose
Category Label: Nose

Item 18

Label: Chronic coughing
Item ID: mouth-throat-1
Category ID: mouth-throat
Category Label: Mouth/throat

Item 19

Label: Gagging, frequent need to clear throat
Item ID: mouth-throat-2
Category ID: mouth-throat
Category Label: Mouth/throat

Item 20

Label: Sore throat, hoarseness, loss of voice
Item ID: mouth-throat-3
Category ID: mouth-throat
Category Label: Mouth/throat

Item 21

Label: Swollen or discolored tongue, gums, lips
Item ID: mouth-throat-4
Category ID: mouth-throat
Category Label: Mouth/throat

Item 22

Label: Canker sores
Item ID: mouth-throat-5
Category ID: mouth-throat
Category Label: Mouth/throat

Item 23

Label: Acne
Item ID: skin-1
Category ID: skin
Category Label: Skin

Item 24

Label: Hives, rashes, dry skin
Item ID: skin-2
Category ID: skin
Category Label: Skin

Item 25

Label: Hair loss
Item ID: skin-3
Category ID: skin
Category Label: Skin

Item 26

Label: Flushing, hot flashes
Item ID: skin-4
Category ID: skin
Category Label: Skin

Item 27

Label: Excessive sweating
Item ID: skin-5
Category ID: skin
Category Label: Skin

Item 28

Label: Irregular or skipped heartbeat
Item ID: heart-1
Category ID: heart
Category Label: Heart

Item 29

Label: Rapid or pounding heartbeat
Item ID: heart-2
Category ID: heart
Category Label: Heart

Item 30

Label: Chest pain
Item ID: heart-3
Category ID: heart
Category Label: Heart

Item 31

Label: Chest congestion
Item ID: lungs-1
Category ID: lungs
Category Label: Lungs

Item 32

Label: Asthma, bronchitis
Item ID: lungs-2
Category ID: lungs
Category Label: Lungs

Item 33

Label: Shortness of breath
Item ID: lungs-3
Category ID: lungs
Category Label: Lungs

Item 34

Label: Difficulty breathing
Item ID: lungs-4
Category ID: lungs
Category Label: Lungs

Item 35

Label: Nausea, vomiting
Item ID: digestive-1
Category ID: digestive
Category Label: Digestive tract

Item 36

Label: Diarrhea
Item ID: digestive-2
Category ID: digestive
Category Label: Digestive tract

Item 37

Label: Constipation
Item ID: digestive-3
Category ID: digestive
Category Label: Digestive tract

Item 38

Label: Bloated feeling
Item ID: digestive-4
Category ID: digestive
Category Label: Digestive tract

Item 39

Label: Belching, passing gas
Item ID: digestive-5
Category ID: digestive
Category Label: Digestive tract

Item 40

Label: Heartburn
Item ID: digestive-6
Category ID: digestive
Category Label: Digestive tract

Item 41

Label: Intestinal/stomach pain
Item ID: digestive-7
Category ID: digestive
Category Label: Digestive tract

Item 42

Label: Pain or aches in joints
Item ID: joints-muscles-1
Category ID: joints-muscles
Category Label: Joints/muscles

Item 43

Label: Arthritis
Item ID: joints-muscles-2
Category ID: joints-muscles
Category Label: Joints/muscles

Item 44

Label: Stiffness or limitation of movement
Item ID: joints-muscles-3
Category ID: joints-muscles
Category Label: Joints/muscles

Item 45

Label: Pain or aches in muscles
Item ID: joints-muscles-4
Category ID: joints-muscles
Category Label: Joints/muscles

Item 46

Label: Feeling of weakness or tiredness
Item ID: joints-muscles-5
Category ID: joints-muscles
Category Label: Joints/muscles

Item 47

Label: Binge eating/drinking
Item ID: weight-1
Category ID: weight
Category Label: Weight

Item 48

Label: Craving certain foods
Item ID: weight-2
Category ID: weight
Category Label: Weight

Item 49

Label: Excessive weight
Item ID: weight-3
Category ID: weight
Category Label: Weight

Item 50

Label: Compulsive eating
Item ID: weight-4
Category ID: weight
Category Label: Weight

Item 51

Label: Water retention
Item ID: weight-5
Category ID: weight
Category Label: Weight

Item 52

Label: Underweight
Item ID: weight-6
Category ID: weight
Category Label: Weight

Item 53

Label: Fatigue, sluggishness
Item ID: energy-1
Category ID: energy
Category Label: Energy/activity

Item 54

Label: Apathy, lethargy
Item ID: energy-2
Category ID: energy
Category Label: Energy/activity

Item 55

Label: Hyperactivity
Item ID: energy-3
Category ID: energy
Category Label: Energy/activity

Item 56

Label: Restlessness
Item ID: energy-4
Category ID: energy
Category Label: Energy/activity

Item 57

Label: Poor memory
Item ID: mind-1
Category ID: mind
Category Label: Mind

Item 58

Label: Confusion, poor comprehension
Item ID: mind-2
Category ID: mind
Category Label: Mind

Item 59

Label: Poor concentration
Item ID: mind-3
Category ID: mind
Category Label: Mind

Item 60

Label: Poor physical coordination
Item ID: mind-4
Category ID: mind
Category Label: Mind

Item 61

Label: Difficulty in making decisions
Item ID: mind-5
Category ID: mind
Category Label: Mind

Item 62

Label: Stuttering or stammering
Item ID: mind-6
Category ID: mind
Category Label: Mind

Item 63

Label: Slurred speech
Item ID: mind-7
Category ID: mind
Category Label: Mind

Item 64

Label: Learning disabilities
Item ID: mind-8
Category ID: mind
Category Label: Mind

Item 65

Label: Mood swings
Item ID: emotions-1
Category ID: emotions
Category Label: Emotions

Item 66

Label: Anxiety, fear, nervousness
Item ID: emotions-2
Category ID: emotions
Category Label: Emotions

Item 67

Label: Anger, irritability, aggressiveness
Item ID: emotions-3
Category ID: emotions
Category Label: Emotions

Item 68

Label: Depression
Item ID: emotions-4
Category ID: emotions
Category Label: Emotions

Item 69

Label: Frequent illness
Item ID: other-1
Category ID: other
Category Label: Other

Item 70

Label: Frequent or urgent urination
Item ID: other-2
Category ID: other
Category Label: Other

Item 71

Label: Genital itch or discharge
Item ID: other-3
Category ID: other
Category Label: Other

Section Totals

Lookback window

Clinical Interpretation Edited

Not Provided Score

WHO-5 Administered

WHO-5 Below Threshold

Determinants Spokes

Item 1

Label: Sleep and Rest
Spoke ID: sleep-rest

Item 2

Label: Nutrition
Spoke ID: nutrition

Item 3

Label: Movement
Spoke ID: movement

Item 4

Label: Stress Load
Spoke ID: stress-load

Item 5

Label: Relationships
Spoke ID: relationships

Item 6

Label: Environment
Spoke ID: environment

Item 7

Label: Purpose
Spoke ID: purpose

Item 8

Label: Community
Spoke ID: community

Item 9

Label: Resilience
Spoke ID: resilience

Item 10

Label: Access and Resources
Spoke ID: access-resources

Status

active

Variant

adult

Who5 Items

Item 1

Label: Cheerful and in Good Spirits
Item ID: who5-1

Item 2

Label: Calm and Relaxed
Item ID: who5-2

Item 3

Label: Active and Vigorous
Item ID: who5-3

Item 4

Label: Fresh and Rested
Item ID: who5-4

Item 5

Label: Daily Life Filled with Interest
Item ID: who5-5

Who5 Instrument Version

who5-v1

Promis10 Instrument Version

promis10-adult-v1

Past Medical & Family History

Allergies and reactions:

Immunizations / screening:

Surgical history:

Family history:

Pregnancy / menstrual status if applicable:

Consent and privacy acknowledgements completed.

Plan and Follow-Up

Focus	Documentation
Assessment	Clinical impression, diagnostic formulation, severity, strengths, barriers, and uncertainty. Clinical impression: Differential / rule-outs: Strengths and barriers:
Initial plan	Planned modality, frequency, measures, referrals, coordination, and patient goals. Treatment focus: Frequency / measures: Referrals / coordination:
Risk / follow-up	Risk status, safety actions when indicated, next appointment, and items to complete before then. Risk status: Follow-up interval: Before next visit:

Focus

Documentation

Assessment

Clinical impression, diagnostic formulation, severity, strengths, barriers, and uncertainty.

Clinical impression:

Differential / rule-outs:

Strengths and barriers:

Initial plan

Planned modality, frequency, measures, referrals, coordination, and patient goals.

Treatment focus:

Frequency / measures:

Referrals / coordination:

Risk / follow-up

Risk status, safety actions when indicated, next appointment, and items to complete before then.

Risk status:

Follow-up interval:

Before next visit:

Pre-Visit Intake

Diagnosis Snapshot

Stored Payload

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Details

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ND - Intake Questionnaire Form

Preview