|
Chief Complaint
• • •
|
Chief complaint
|
|
History of the Present Illness
|
|
|
Narrative
|
|
|
Character of pain
|
|
|
Frequency
|
Duration
|
|
Quality
|
|
|
VAS Score
|
Quality Cont
• • •
|
|
History of the pain
|
|
|
Triggers
• • •
|
Diurnal
• • •
|
|
Duration
• • •
|
Etiology
• • •
|
|
Treatment
• • •
|
Treatment Comments
|
|
|
|
|
Medical History
|
|
|
Past Medical History
• • •
|
Past Medical History Freewrite
|
|
Past Surgical History
• • •
|
Past Surgical Hist Comments
|
|
Childhood illnesses
• • •
|
Childhood Illness Comments
|
|
Date of last PE
|
|
|
Social History
|
|
|
Occupation
|
Currently Working
|
|
Occupation Cont
• • •
|
Date of Injury
|
|
Caffeine
|
Caffeine Comments
|
|
Alcohol
|
Alcohol Comments
|
|
Other illegal substances
|
|
|
Medications
|
Allergies
|
|
Review of Systems
|
|
|
GENERAL [-]
|
General ROS+
• • •
|
|
General ROS Comments
|
|
|
HEENT [-]
|
HEENT ROS+
• • •
|
|
HEENT ROS Comments
|
|
|
Cardiovascular [-]
|
Cardiovascular ROS+
• • •
|
|
CV ROS Comments
|
|
|
Respiratory [-]
|
Respiratory ROS+
• • •
|
|
Resp ROS Comments
|
|
|
Gastrointestinal [-]
|
GI ROS+
• • •
|
|
GI ROS Comments
|
|
|
Genitourinary [-]
|
Genitourinary ROS+
• • •
|
|
Genitourinary ROS Comments
|
|
|
Neurological [-]
|
Neurological ROS+
• • •
|
|
Neuro ROS Comments
|
|
|
Musculoskeletal [-]
|
MSK ROS+
• • •
|
|
MSK ROS Comments
|
|
|
Hematological [-]
|
Hematologic ROS+
• • •
|
|
Hematologic ROS Comments
|
|
|
Skin [-]
|
Skin ROS+
• • •
|
|
Skin ROS Comments
|
|
|
Endocrine [-]
|
Endocrine ROS+
• • •
|
|
Endo ROS Comments
|
|
|
Physical Exam
|
|
|
General WNL
|
General Abnormal
• • •
|
|
General Comments
|
|
|
HEENT WNL
|
HEENT Abnormal
• • •
|
|
HEENT Comments
|
|
|
Skin WNL
|
Skin Lesion
|
|
Skin Comments
|
|
|
Neck WNL
|
Neck Abnormal
• • •
|
|
Neck Comments
|
|
|
Cardiovascular WNL
|
Cardiovascular Abnormal
• • •
|
|
Cardiovascular Comments
|
|
|
Lungs WNL
|
Lungs Abnormal
• • •
|
|
Lungs Comments
|
|
|
Abdomen WNL
|
Abdomen Abnormal
• • •
|
|
Abdomen Comments
|
|
|
Lymph WNL
|
Lymph Abnormal
• • •
|
|
Lymph Comments
|
|
|
Rectal WNL
|
Rectal Abnormal
• • •
|
|
Rectal Comments
|
|
|
Neuro WNL
|
Neuro Abnormal
• • •
|
|
Neuro Comments
|
|
|
Extremities WNL
|
Extrem Abnormal
• • •
|
|
Extrem Comments
|
|
|
Alignment/Gait
• • •
|
Abnormal Comments
|
|
Physical - Back Pain
|
Back Pain - Appearance
• • •
|
|
Abnormality Comments
|
|
|
Palpation
• • •
|
|
|
AROM- fwd flex (75 deg)
|
AROM- hyper ext (20 deg)
|
|
AROM- lat flex (20-30 deg)
|
AROM- rotation (40 deg)
|
|
Specific Tests
|
Straight leg raising (Deg)
|
|
Lhermitte’s sign
• • •
|
SI joint
• • •
|
|
Wadell’s
• • •
|
Piriformis stretch
• • •
|
|
Leg length discrepancy
|
|
|
Motor testing of all muscle groups
/
|
Deep tendon reflexes
• • •
|
|
Sensory loss
• • •
|
|
|
|
|
|
Laboratory Results
|
|
|
Imaging & other studies
|
|
|
Assessment & Plan
|
|
