|
Start date for injury
|
New in last 60 days?
• • •
|
|
Last condition treated
|
Result of last treatment?
|
|
Precipitating event?
|
Precipitating event was?
|
|
|
|
|
Date of onset
|
Date of initial evaluation
|
|
Date of current findings
|
|
|
|
|
|
Pain location
• • •
|
Pain Quality
• • •
|
|
Primary functional limitation
|
% improved?
|
|
Pre-treatment Pain Level
• • •
|
Pre-treatment Pain Freq
|
|
Post-treatment Pain Level
• • •
|
Post-treatment Pain Freq
|
|
# days relief
|
Pain History
|
|
|
|
|
Temperature
• • •
|
Energy
• • •
|
|
Sleep
• • •
|
Digestion
• • •
|
|
Appetite
• • •
|
Thirst
• • •
|
|
Bowel Movements
• • •
|
Urination
• • •
|
|
Sweating
• • •
|
Stress
• • •
|
|
Lungs
• • •
|
Cough?
• • •
|
|
Sputum?
• • •
|
Sinus/Allergy
• • •
|
|
Sputum?
• • •
|
Heart
• • •
|
