|
New patient
|
F/U
|
|
Est pt/new problem
|
2nd opinion
|
|
Chief complaint
• • •
|
R/L foot/ankle
|
|
Associated CC
• • •
|
complaint comment
|
|
DOI/onset of pain
• • •
|
DOI Comment
|
|
Specific injury [+]
|
Specific injury [-]
|
|
MOI [+]
• • •
|
MOI comment
|
|
Result of MOI
• • •
|
|
|
Exacerbations [+]
• • •
|
|
|
Alleviating factors [+]
• • •
|
Alleviating factors comments
|
|
Onset/Timing
|
|
|
Severity
|
Severity scale
• • •
|
|
Nature of pain
• • •
|
|
|
NIght time pain [+]
|
Nightime pain [-]
|
|
Previous treatment [-]
|
Previous treatment [+]
• • •
|
|
Previous treatment results
|
Previous treatment comments
|
|
Limitation [-]
|
Limitation [+]
• • •
|
|
Patient located pain
• • •
|
Patient located pain comment
|
