|
What are we seeing you for today?
• • •
|
Affected Body Part(s)
• • •
|
|
Type of Surgery
|
Date of Surgery
|
|
Surgery Center
|
|
|
Pain on a scale of 1-10 Today
• • •
|
How would you describe the pain?
• • •
|
|
What makes the pain worse?
• • •
|
Other/ Free Text Box
|
|
What relieves the pain?
• • •
|
Other/ Free Text Box
|
|
Have symptoms improved since last visit?
|
|
|
Complaints of Fever/Chills/Nausea/Headache?
|
If Yes, Complaints of:
• • •
|
|
Taking Medication for pain/discomfort?
|
If yes, Which medications?
|
|
Any complications?
|
If yes, please describe
|
|
Sutures Removed Today?
|
|
|
Using Assistive Device?
|
If yes, please select
• • •
|
|
Wearing Brace/Sling?
|
|
|
Has the patient started PT?
|
Treatment results
|
|
Given PT Script today?
|
|
|
Other treatment plan/ Free Text Box
|
|
|
Work Status
|
|
