|
Have you reviewed Check-In information?
|
Provider Summary of Intake (Required)
|
|
Alleviating Factors
|
Aggravating Factors
|
|
When are symptoms the worst
• • •
|
Rehab Goals
|
|
Imaging
• • •
|
Imaging Results
|
|
Rehab Precautions (post-op)
|
Next Physician Visit
|
|
Referral Source (be specific)
|
|
|
|
|
|
History/Exam Reviewed? (*DC Only)
|
Additional Information
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Location of Primary Complaint
• • •
|
|
|
Quality of Symptoms
• • •
|
|
|
Pain Rating /10 (VNRS)
• • •
|
|
|
Mechanism of Onset
|
Date of Injury (mm/dd/yyyy)
|
|
Are these symptoms related to an auto accident?
|
Are these symptoms work related?
|
|
Frequency of Symptoms
|
|
|
Duration Since Onset
|
|
|
Alleviating Factors
|
|
|
Aggravating Factors
|
|
|
Past History of These Symptoms
|
If yes, when?
|
|
Previously Treated for These Symptoms
|
If yes, by whom? (name and title)
|
|
Functional Limitations
|
|
|
Red Flags
• • •
|
|
|
|
|
|
Additional Complaints
|
|
