|
Date of Onset
|
Context
|
|
HPI
|
|
|
Neck Pain [+]
|
|
|
VAS Neck Low
|
VAS Neck High
|
|
Radiating Pain?
|
|
|
Location from:
• • •
|
|
|
Laterality
|
Location to:
|
|
Additional Neck Pain Location?
|
|
|
Additional Radiating Pain?
|
|
|
Additional Location from:
• • •
|
Additional Laterality
|
|
Additional Location to:
|
|
|
Numbness/Tingling?
|
Numbness/Tingling Comment
|
|
Neck Pain Comments
|
|
|
Mid Back Pain [+]
|
|
|
VAS MBP Low
|
VAS MBP High
|
|
Radiating Pain?
|
|
|
Location from:
• • •
|
Laterality
|
|
Location to:
|
|
|
Numbness/Tingling?
|
Numbness/Tingling Comment
|
|
MBP Comments
|
|
|
Lower Back Pain [+]
|
|
|
VAS LBP Low
|
VAS LBP High
|
|
Radiating Pain?
|
Location from:
• • •
|
|
Laterality
|
Location to:
|
|
Additional LBP Location?
|
|
|
Additional Radiating Pain?
|
Additional Laterality
|
|
Additional Location from:
• • •
|
Additional Location to:
|
|
Numbness/Tingling?
|
Numbness/Tingling Comment
|
|
LBP Comments
|
|
|
Additional Complaints
|
Body Diagram
|
|
Do these activities affect pain?
|
Neck/Back Pain Locations
• • •
|
|
Sitting
|
Standing
|
|
Walking
|
Twisting
|
|
Laying Down
|
Bending Forward
|
|
Backward Bending
|
Coughing/Sneezing
|
|
Additional Activities Affecting Pain
|
|
|
Any activities/hobbies now limited/unable to do?
|
|
|
Patient Concerns
• • •
|
Concerns Comments
|
|
Bowel/Bladder Dysfunction?
|
B/B Dysfunction Comment
|
|
Difficulty Sleeping?
|
Awakened by Pain?
|
|
Pain in morning?
• • •
|
Pain Affected Sexual Function?
|
|
Pregnant? (Leave Blank if Male)
|
|
