|
NEW: The patient presents today with...1
• • •
|
NEW: The patient presents today with...2
• • •
|
|
NEW: also with radiating symptoms
• • •
|
NEW: Has the patient experienced this before?
|
|
|
|
|
RE-E: The patient presents today with...
• • •
|
RE-E: History of Injury
• • •
|
|
Month
|
Day
|
|
Year
|
RE-E: "Initial" Diagnoses
• • •
|
|
RE-E: also with radiating symptoms
• • •
|
RE-E: Add'l or other Drs/Tx?
• • •
|
|
RE-E: Pt's Medication
• • •
|
RE-E: Previous Records?
|
|
RE: Imaging/Testing:
• • •
|
RE: see reports statement
• • •
|
|
|
|
|
Quality/Type of Pain
• • •
|
Severity on 1 or ALL areas of complaints
|
|
Severity / Intensity 1° injuy (MULT INJ)
|
Severity / Intensity 2° injury
|
|
Severity / Intensity 3° injury
|
Complicating Factor to note
|
|
How often are symptoms present?
|
Associated Symptoms
• • •
|
|
Denies anything relieves symptoms.
|
What makes it feel better?
• • •
|
|
What makes the pain worse?
• • •
|
What ADLs are difficult to perform?
• • •
|
|
|
|
|
WC injury DEGREE of CERTANTY
|
MVA injury DEGREE of CERTANTY
|
|
Slip & Fall injury DEGREE of CERTANTY
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Quality
• • •
|
Quality Comments
|
|
Severity
|
Severity Comments
|
|
Frequency
• • •
|
Frequency Comments
|
|
Onset
• • •
|
Onset Comments
|
|
When does pain occur?
• • •
|
When Comments
|
|
Modifying Factors
• • •
|
Modifying Factors Comments
|
|
Radiating Symptoms
• • •
|
Radiating Symptoms Comments
|
|
Previous Treatment
• • •
|
Previous Treatiment Comments
|
|
Provocative
• • •
|
Provocative Commments
|
|
Palliative
• • •
|
Paliative Comments
|
