|
Date of Onset
|
Mode of Onset
|
|
HPI
|
|
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Neck Pain [+]
|
|
|
VAS Neck Low
|
VAS Neck High
|
|
Radiating Pain?
|
|
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Location from:
• • •
|
|
|
Laterality
|
Location to:
• • •
|
|
Numbness/Tingling?
|
Numbness/Tingling Comment
|
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Weakness
|
Weakness comments
|
|
Neck Pain Comments
|
|
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Mid Back Pain [+]
|
|
|
VAS MBP Low
|
VAS MBP High
|
|
Radiating Pain?
|
|
|
Location from:
• • •
|
Laterality
|
|
Location to:
• • •
|
|
|
Numbness/Tingling?
|
Numbness/Tingling Comment
|
|
Weakness
|
Weakness comments
|
|
MBP Comments
|
|
|
Lower Back Pain [+]
|
|
|
VAS LBP Low
|
VAS LBP High
|
|
Radiating Pain?
|
|
|
Location from:
• • •
|
Laterality
|
|
Location to:
• • •
|
|
|
Numbness/Tingling?
|
Numbness/Tingling Comment
|
|
Weakness
|
Weakness comments
|
|
LBP Comments
|
|
|
Additional Complaints
|
Body Diagram
|
|
Pain is described as:
• • •
|
|
|
Pain is aggravated by
• • •
|
Comments
|
|
Pain is alleviated by
• • •
|
Comments
|
|
Pain is
• • •
|
|
|
Bowel/Bladder Dysfunction?
|
B/B Dysfunction Comment
|
|
Pain interferes with
• • •
|
Concerns Comments
|
|
Patient concerns
• • •
|
|
|
Any activities/hobbies now limited/unable to do?
|
|
|
PAST Treatments:
|
|
|
Chiropractic Treatment:
|
Comments
|
|
Physical Therapy:
|
Comments
|
|
Acupuncture Treatment:
|
Comments
|
|
X-Ray Studies:
|
Comments
|
|
MRI/CT Studies:
|
Comments
|
|
EMG Studies:
|
Comments
|
|
MEDICATIONS Tried:
|
|
|
Anti-seizure meds:
• • •
|
Comments
|
|
Antidepressants:
• • •
|
Comments
|
|
Muscle relaxants:
• • •
|
Comments
|
|
Opioids:
|
Comments
|
|
NSAIDs:
• • •
|
Comments
|
|
Topical cream or patches:
• • •
|
Comments
|
|
Oral Steroids:
• • •
|
Comments
|
