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Have Patient Fill out Pain Drawing
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Pain Diagram
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Add Referring Doctor (under additional tab)
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Chief Complaint: Initial evaluation of .....
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Pain Level Today
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Average Pain Level Last 7 Days
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When is the pain the worst?
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When is pain the worst(free text)
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When is your pain the least?
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When is pain the least?(free text)
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How often does the pain occur?
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How often does pain occur?(free text)
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Are their activites avoided because of pain?
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Activities Avoided Include (free text)
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Activitie Avoided Pick List
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How well are you sleeping?
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Been Treated by a Pain Doctor Before?
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Pain Treatments Tried By Other Doctor
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Pain Location #1 is? (Place on body)
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Pain Location #1 Began?
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Pain Location #1 Description(pick list)
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Pain Location #1 Description(free text)
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Pain Location #1 Muscle Spasms?
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Pain Location #1 Muscle Spasm?(free text)
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Pain Location #1 Weakness?
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Pain Location #1 Weakness? (free text)
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Activities that increase Pain (pick list)
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Activities that increase Pain (free text)
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Pain Location #1 Treatments Tried?
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Treatments tried for Pain Location #1(free text)
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Treatments that helped Location #1
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Treatments that helped Location #1(free text)
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Location #1 related to injury?
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Location #1 Injury Mechanism: (sustained ....)
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Pain Location #1 General Comments
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Pain Location #2 is? (Place on body)
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Pain Location #2 Began?
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Pain Location #2 Description(pick list)
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Pain Location #2 Description(free text)
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Pain Location #2 Muscle Spasms?
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Pain Location #2 Muscle Spasm?(free text)
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Pain Location #2 Weakness?
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Pain Location #2 Weakness? (free text)
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Activities that increase Pain (pick list)
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Activities that increase Pain (free text)
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Pain Location #2 Treatments Tried?
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Treatments tried for Pain Location #2(free text)
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Treatments that helped Location #2
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Treatments that helped Location #2(free text)
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Location #2 related to injury?
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Injury Location #2 Same As Stated Above?
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Location #2 Mechanism: (sustained ....)
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Pain Location #2 General Comments
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Pain Location #3 is? (Place on body)
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Pain Location #3 Began?
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Pain Location #3 Description(pick list)
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Pain Location #3 Description(free text)
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Pain Location #3 Muscle Spasms?
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Pain Location #3 Muscle Spasm?(free text)
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Pain Location #3 Weakness?
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Pain Location #3 Weakness? (free text)
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Activities that increase Pain (pick list)
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Activities that increase Pain (free text)
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Pain Location #3 Treatments Tried?
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Treatments tried for Pain Location #3(free text)
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Treatments that helped Location #3
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Treatments that helped Location #3(free text)
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Location #3 related to injury?
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Injury Location #3 Same As Stated Above?
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Location #3 Mechanism: (sustained ....)
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Pain Location #3 General Comments
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