|
Chief Complaint
|
|
|
New Patient Visit
|
Subsequent visit
|
|
Maintenance Visit
|
|
|
Chief Complaint
• • •
|
|
|
Location
• • •
|
Location Freeform
|
|
Onset
• • •
|
Onset Freeform
|
|
Quality
• • •
|
Severity
|
|
Radiation
|
Radiation continued
|
|
Palliative
|
Provocative
|
|
Timing
• • •
|
|
|
Previous occurances
|
Previous occurrence resolved?
|
|
Secondary Chief Complaint
|
|
|
Chief Complaint
• • •
|
|
|
Location
• • •
|
Location Freeform
|
|
Onset
• • •
|
Onset Freeform
|
|
Quality
• • •
|
Severity
|
|
Radiation
|
Radiation continued
|
|
Palliative
|
Provocative
|
|
Timing
• • •
|
|
|
Previous occurances
|
Previous occurrence resolved?
|
|
Subjective Freeform
|
|
|
Car Accident
|
|
|
Date of Accident
|
Claim Number
|
|
Driver/Passenger
|
Struck on the
|
|
Air bags deployed?
|
Looking
|
|
Seatbelts?
|
What did patient strike in car
• • •
|
|
Unconscious?
|
Immed. Pain
• • •
|
|
Where did patient go?
• • •
|
|
|
Imaging and treatment?
• • •
|
Additional Treatment
• • •
|
|
Getting better/worse
|
|
|
Medical History
|
|
|
Past Medical History
• • •
|
|
|
Surgical History
|
|
|
Other Pertinent Info
|
|
|
Family History
|
|
|
Family History
• • •
|
Other Pertinent Info
|
|
Social History
|
|
|
Occupation
|
Sleep
|
|
Alcohol
|
Tobacco
|
|
Caffiene
• • •
|
Stress level
|
|
Other Pertinent Info
|
|
