|
Date of onset
|
Mode of onset
|
|
Location of complaint
|
Type of pain
|
|
Other systems involved
|
Other treatments sought and effects
|
|
1. Chief Complaint______
|
2. History of condition:onset,course & treatment
|
|
3. Pain (or presenting symptom)
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Position
|
|
Character
|
Frequency
|
|
Duration
|
4. Aggravating Factors
|
|
5. Relieving Factors
|
6. Associated Symptoms
|
|
7. SYSTEMS REVIEW
|
8. PRIOR ILLNESS, SURGERY, ACCIDENT
|
|
9. FAMILY HISTORY
|
10. PSYCHO-SOCIAL HISTORY
|
|
11. DRUGS AND CHEMICALS (PAST OR PRESENT)
|
12. HOME/HOBBY/RECREATIONAL/OCCUPATIONAL FACTORS
|
