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Chief Complaint
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What brings you in today?
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How long has THIS INSTANCE been bothering you?
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What were you doing when the pain started?
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When was the FIRST time you had this problem?
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Pain Level Today
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Pain at it's worst
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Currently Medicated for this complaint?
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If yes, with what medication?
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Describe the Pain
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How long does the pain last?
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Does it radiate into your arms/legs?
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Describe if yes
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How often does it occur?
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What activities make it worse?
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What do you do that makes it feel better?
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Complaint 2
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What brings you in today?
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How long has THIS INSTANCE been bothering you?
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What were you doing when the pain started?
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When was the FIRST time you had this problem?
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Pain Level Today
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Pain at it's worst
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Currently Medicated for this complaint?
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If yes, with what medication?
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Describe the Pain
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How long does the pain last?
• • •
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Does it radiate into your arms/legs?
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Describe if yes
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How often does it occur?
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What activities make it worse?
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What do you do that makes it feel better?
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Complaint 3
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What brings you in today?
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How long has THIS INSTANCE been bothering you?
• • •
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What were you doing when the pain started?
• • •
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When was the FIRST time you had this problem?
• • •
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Pain Level Today
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Pain at it's worst
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Currently Medicated for this complaint?
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If yes, with what medication?
• • •
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Describe the Pain
• • •
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How long does the pain last?
• • •
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Does it radiate into your arms/legs?
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Describe if yes
• • •
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How often does it occur?
• • •
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What activities make it worse?
• • •
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What do you do that makes it feel better?
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History of broken bones, MVA's, knocked unconscious, surgeries, etc.
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Other Treatments that have NOT helped
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Additional Medical Input
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Explanation of work and/or ADL's
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What activities does this prevent you from doing either partially or totally that you would like to be able to do again?
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Do you have cancer?
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If YES, when and where?
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Are you cancer free?
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If NO please explain
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