| Content | Form 1 Maximum | Form 2 | Form 3 Minimum | Control AVS | |
|---|---|---|---|---|---|
| Clinics 1 and 2 | Clinics 3 and 4 | ||||
| Patient name, visit date | ✓ | ✓ | ✓ | ✓ | ✓ |
| Chief complaint | ✓ | ✓ | |||
| Allergies | ✓ | ✓ | |||
| Immunizations | ✓ | ✓ | |||
| Vital signs | ✓ | ✓ | ✓ | ||
| Medications | ✓ | ✓ | ✓ | ✓ | ✓ |
| Diagnosis | ✓ | ✓ | ✓ | ✓ | ✓ |
| Problem list | ✓ | ✓ | |||
| Lab orders | ✓ | ✓ | |||
| Physician's contact information | ✓ | ✓ | ✓ | ✓ | ✓ |
| Follow-up appointments/referrals | ✓ | ✓ | ✓ | ✓ | ✓ |
| Instructions (free text) | ✓ | ✓ | ✓ | ✓ | ✓ |