VISIT TYPE

WORK COMP

URGENT CARE / PHYSICAL

NEW

NEW

FOLLOW UP

FOLLOW UP

PROCEDURE

EMERGENCY

JOB DETAILS

Employer

Date of Injury

Work Comp Insurance

Claim #

Job Title

Job Title (If not found in drop-down)

Length of employment

Average hours per week

Other employment?

Comments (including title and dates)

Job requirements at the time of injury

Comments

Lifting / Pushing / Pulling Weight Maximum

Comments

Any lost work time?

Last date worked

INTERPRETER

Interpreter

Interpreter Name, ID and Company

HPI

INJURY

ILLNESS

PHYSICAL

Parent or guardian present

Parent / Guardian Name

Pediatrician

Pediatrician

Patient's primary concern is

Comments

Mechanism

Comments

Location

Comments

Quality

Comments

Severity

Comments

Duration

Comments

Timing

Comments

Context (occurs with...)

Comments

Better with

Comments

Worse with

Comments

Associated Symptoms

Associated Symptoms

Other associated symptoms

History of previous or recurrent infection of the same body part?

History of previous pain, injury or surgery to this body part?

Ongoing treatment?

Exposed to others with similar symptoms?

Flu vaccine given this season?

Recent antibiotic use (3 months)?

Recent travel out of U.S.?

Comments

Additional Work Comp Info

Chemical or toxic exposure?

Comments

Previous occupational injuries?

If Yes (year, body part, side, status)

Pre-existing conditions that could complicate the patient's diagnosis, treatment, and/or rate of recovery?

Comments

Prior acute trauma or cumulative trauma to the affected body part?

Comments

Any ongoing treatment for the prior trauma or exposure?

Comments

Related hobbies / sports complications?

Comments

FEMALE

Female YES

Post-menopausal

Preadolescent

Pregnant?

Breast feeding?

Last menstrual period

OBGYN

Comments

CHANGES TO MEDICAL HISTORY

Changes to medical history since last visit?

Changes include:

ROS REVIEWED

Patient's history and ROS reviewed

PHYSICAL EXAM

VITALS

Vitals

Comments

Dominant Hand

CONSTITUTIONAL

Constitutional WNL

EXAM

Abnormals

Normals

Comments

PSYCHIATRIC

Psychiatric WNL

EXAM

Abnormals

Comments

Normals

Comments

SKIN

Skin WNL

EXAM

Abnormals

Comments

Normals

Comments

HEAD

Head WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

Comments

EYES

EYES WNL

EXAM

Abnormals

Normals

Comments

ENT

ENT WNL

EXAM

Abnormals

Normals

Comments

NECK

Neck WNL

EXAM

Neck Abnormals

Neck Normals

Palpation Abnormals

Palpation Normals

ROM

Comments

LYMPHATICS

Lymphatics WNL

EXAM

Abnormals

Comments

CARDIOVASCULAR

Cardiovascular WNL

EXAM

Abnormals

Normals

Comments

LUNGS

Lungs WNL

EXAM

Abnormals

Normals

Lungs Comments

ORTHOPEDIC

View orthopedic exam

LEFT SHOULDER

Left Shoulder WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

Special Tests Abnormals

Special Tests Normals

ROM

Comments

Strength

Comments

RIGHT SHOULDER

Right Shoulder WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

Special Tests Abnormals

Special Tests Normals

ROM

Comments

Strength

Comments

LEFT ELBOW

Left Elbow WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

Special Tests Abnormals

Special Tests Normals

ROM

Comments

Strength

Comments

RIGHT ELBOW

Right Elbow WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

Special Tests Abnormals

Special Tests Normals

ROM

Comments

Strength

Comments

LEFT FOREARM

Left Forearm WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation normals

Special Tests Abnormals

Special Tests Normals

ROM

Comments

Strength

Comments

RIGHT FOREARM

Right Forearm WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation normals

Special Tests Abnormals

Special Tests Normals

ROM

Comments

Strength

Comments

LEFT WRIST

Left Wrist WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

Special Tests Abnormals

Special Tests Normals

ROM

Comments

Strength

Comments

RIGHT WRIST

Right Wrist WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

Special Tests Abnormals

Special Tests Normals

ROM

Comments

Strength

Comments

LEFT HAND

Left Hand/fingers WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

Special Tests Abnormals

Special Tests Normals

ROM

Comments

Strength

Comments

RIGHT HAND

Right hand WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

Special Tests Abnormals

Special Tests Normals

ROM

Comments

Strength

Comments

LEFT HIP

Left Hip WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

Special Tests Abnomals

Special Tests Normals

ROM

Comments

Strength

Comments

RIGHT HIP

Right Hip WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation normal

Special Tests Abnomals

Special Tests Normals

ROM

Comments

Strength

Comments

LEFT KNEE

Left Knee WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

Special Tests Abnomals

Special Tests Normals

ROM

Comments

Strength

Comments

RIGHT KNEE

Right Knee WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

Special Tests Abnomals

Special Tests Normals

ROM

Comments

Strength

Comments

Other right leg normals

Comments

LEFT ANKLE

Left Ankle WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

Special Tests Abnormals

Special Tests Normals

ROM

Comments

Strength

Comments

RIGHT ANKLE

Right Ankle WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

Special Tests Abnormals

Special Tests Normals

ROM

Comments

Strength

Comments

LEFT FOOT

Left foot WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

ROM

Comments

Strength

Comments

RIGHT FOOT

Right Foot WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

ROM

Comments

Strength

Comments

BACK

Back WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

Special Tests Abnormals

Special Tests Normals

ROM

Comments

ABDOMEN / GROIN

Abdomen/Groin WNL

EXAM

Inspection Abnormals

Inspection Normals

Auscultation

Palpation Abnormals

Abdomen/Groin Palpation Normals

Special Tests Abnormals

Special Tests Normals

Comments

NEUROLOGICAL

Sensation WNL

Strength WNL

DTR WNL

Cranial nerves II-XII WNL

Cerebellar Testing WNL

NEURO EXAM

Sensation Abnormals

Sensation Normals

DTR Abnormals

DTR Normals

Cranial Nerves

Comments

Strength

Comments

STUDIES / TESTS / LABS

Studies, tests or labs reviewed

Comments

Point of care test performed

Test Performed

Test result

Comments

Urine Dipstick

Leukocyte

Nitrites

Urobilinogen

Protein

pH

Blood

Specific Gravity

Ketone

Bilirubin

Glucose

Comments

A specimen was sent to the laboratory

Comments

X-rays ordered, visualized and discussed with patient

Preliminary read?

Comments

Patient referred for advanced diagnostics

Comments

Diagnostic studies reviewed

Comments

Prior labs reports reviewed

Comments

Laboratory testing recommended

Comments

ADMINISTERED MEDICATION / VACCINE

Medication #1

Medication

Dose

Location

Manufacturer

Expiration

Lot

Comments

Medication #2

Medication

Dose

Location

Manufacturer

Expiration

Lot

Comments

TETANUS STATUS

Last Tetanus Vaccine

INJURY CAUSATION

Findings consistent with injury reported by patient?

Comments

Current injury causing current symptoms?

Comments

Prior factors contributing to findings?

Comments

Findings produced by natural progression or pre-existing conditions?

Comments

Aggravation of a pre-existing condition?

Comments

Work Relatedness

Comments

Exacerbation or Aggravation?

Comments

MEDICAL DECISION MAKING

Previous medical records reviewed?

Time spent reviewing records (min)

Patient's medical history and co-morbidities considered?

Comments

Prescribed medication(s) drug interactions considered?

Comments

Evaluated multiple complaints/diagnoses/body parts?

Comments

RECHECKS ONLY: Assessed treatment complications (infection, Rx SE, etc)?

Comments

PROCEDURES

Procedure performed

Burn care

Description

Ear

Left ear irrigation

Comment

Right ear irrigation

Comment

Bilateral ear irrigation

Comment

Ear Instrumentation

Comments

Eye

Description

Foreign body

Description

Gait training

Description

I&D

Description

Joint aspiration

Description

Joint reduction

Description

Laceration

Description

Nail

Description

Skin

Description

Wart removal

Description

Splinting

Description

Suture / staple removal

Description

ASSESSMENT

PSYCHIATRIC

Anxiety

Depression

Bipolar

Suicidal ideation

SKIN

Seborrheic Dermatitis

Atopic Dermatitis

Dermatitis d/t plants

Dermatitis d/t adhesives

Dermatitis d/t metals

Cancer sore

Coldsore

Herpes genital male

Herpes penial

Herpes vaginal

Shingles

Scabies (non-crusted)

Contact with and (suspected) exposure to pediculosis, acariasis and other infestations

Tinea corporis

Tinea barbae or capitis

Tinea pedis

Tinea unguim

Cellulitis of unspecified part of limb

Cellulitis unspecified finger

Irritant contact dermatitis unspecified

Hand Foot Mouth

Swimmer's itch

Plantar wart

Animal bite

Insect bite (nonvenemous) back/pelvis, initial

Insect bite (nonvenemous) back/pelvis, subsequent

Insect bite (nonvenemous) upper arm, initial

Insect bite (nonvenemous) upper arm, subsequent

Insect bite (nonvenemous) lower leg, initial

Insect bite (nonvenemous) lower leg, subsequent

Sebaceous cyst

Seborrheic dermatitis

HEAD

Tension headache, not intractable

Tension headache, intractable

Migraine without aura, not intractable, without status migrainosus

Migraine with aura, not intractable, without status migrainosus

Post concussive syndrome

EYES

Conjunctivitis d/t adenovirus

Bacterial conjuctivitis left eye

Bacterial conjuctivits of both eyes

Bacterial conjuctivitis right eye

Viral conjunctivitis

Stye right external upper lid

Stye right external lower lid

Stye left external upper lid

Stye left external lower lid

Stye internal, right upper eyelid

Stye internal, right lower eyelid

Stye internal, left upper eyelid

Stye internal, left lower eyelid

ENT

Otitis media left serous

Otitis media right serous

Otitis media left suppurative

Otitis media right suppurative

Otitis externa left

Otitis externa right

Maxillary Sinusitis

Frontal Sinusitis

Ethmoidal Sinusitis

Allergic Rhinitis d/t Pollen

Seasonal Rhinitis

Pharyngitis

Strep Throat Group A

Otalgia right ear

Otalgia left ear

Otalgia bilateral

Upper Respiratory Infection

Impacted cerumen bilateral

Impacted cerumen left

Impacted cerumen right

Influenza A with other manifestations

Influenza other (not A) with other manifestations

NECK

Neck strain, initial

Neck strain, subsequent

LYMPHATICS

CHEST / CARDIAC

Costochondritis

LUNGS

Acute bronchitis

Acute bronchiolitis d/t RSV

Viral pneumonia

Bacterial pneumonia

Cough

Bronchitis and pneumonitis d/t chemicals, gases, fumes and vapor

GENITOURINARY

UTI

Candidiasis vulva and vagina

Dysuria

SHOULDER

SHOULDER PAIN LEFT

SHOULDER PAIN RIGHT

SHOULDER STRAIN LEFT INITIAL

SHOULDER STRAIN RIGHT INITIAL

SHOULDER STRAIN LEFT FU

SHOULDER STRAIN RIGHT FU

BICEPS STRAIN LONG HEAD LEFT INITIAL

BICEPS STRAIN LONG HEAD RIGHT INITIAL

BICEPS STRAIN LONG HEAD LEFT FU

BICEPS STRAIN LONG HEAD RIGHT FU

SHOULDER SPRAIN LEFT INITIAL

SHOULDER SPRAIN RIGHT INITIAL

SHOULDER SPRAIN LEFT FU

SHOULDER SPRAIN RIGHT FU

LABRAL TEAR LEFT INITIAL

LABRAL TEAR RIGHT INITIAL

LABRAL TEAR LEFT FU

LABRAL TEAR RIGHT FU

ROTATOR CUFF TEAR INCOMPLETE LEFT

ROTATOR CUFF TEAR INCOMPLETE RIGHT

ROTATOR CUFF TEAR COMPLETE LEFT

ROTATOR CUFF TEAR COMPLETE RIGHT

BICEPS TEAR LONG HEAD LEFT INITIAL

BICEPS TEAR LONG HEAD RIGHT INITIAL

BICEPS TEAR LONG HEAD LEFT FU

BICEPS TEAR LONG HEAD RIGHT FU

ELBOW

Right lateral epicondylitis

Left lateral epicondylitis

FOREARM

Myositis left foearm

Myositis right forearm

WRIST

WRIST STRAIN RIGHT INITIAL

WRIST STRAIN LEFT INITIAL

WRIST STRAIN RIGHT FU

WRIST STRAIN LEFT FU

WRIST CONTUSION RIGHT INITIAL

WRIST CONTUSION LEFT INITIAL

WRIST CONTUSION RIGHT FU

WRIST CONTUSION LEFT FU

WRIST CARPAL JOINT SPRAIN RIGHT INITIAL

WRIST CARPAL JOINT SPRAIN LEFT INITIAL

WRIST CARPAL JOINT SPRAIN RIGHT FU

WRIST CARPAL JOINT SPRAIN LEFT FU

HAND/FINGERS

Contusion left hand initial

Contusion left hand subsequent

Contusion right hand initial

Contusion right hand subsequent

Strain wrist/hand right initial

Strain wrist/hand right sebsequent

Strain wrist/hand left initial

Strain wrist/hand left subsequent

Dupuytren's contracture

Trigger finger unspecified

Trigger finger right thumb

Trigger finger left thumb

Trigger finger right index finger

Trigger finger left index finger

BACK

LUMBAR STRAIN NEW

LUMBAR STRAIN SUBSEQUENT

LUMBAR PAIN WITH RIGHT RADICULOPATHY

LUMBAR PAIN WITH LEFT RADICULOPATHY

LUMBAR & PELVIS CONTUSION INITIAL

LUMBAR & PELVIS CONTUSION SUBSEQUENT

THORAX BACK WALL STRAIN INITIAL

THORAX BACK WALL STRAIN FU

ABDOMEN/GROIN

Bilateral inguinal hernia, without obstruction/gangrene, recurrent

Bilateral inguinal hernia, without obstruction/gangrene, initial

Umbilical hernia with obstruction, no gangrene

Umbilical hernia without obstruction/gangrene

Inguinal hernia, unilateral, without obstruction/gangrene, new

Inguinal hernia, unilateral, without obstruction/gangrene, subsequent

Abdominal wall strain new

Abdominal wall strain subsequent

Diarrhea unspecified

Vomiting unspecified

GERD without esophagitis

Diverticulitis

Appendicitis

Abdominal pain unspecified

Constipation unspecified

HIP

Trochanteric bursitis unspecified hip

SI joint sprain initial

SI joint sprain subsequent

KNEE

KNEE PAIN LEFT

KNEE PAIN RIGHT

PATELLR TENDINITIS LEFT

PATELLAR TENDINITIS RIGHT

SPRAIN CRUCIATE LEFT INITIAL

SPRAIN CRUCIATE RIGHT INITIAL

KNEE SPRAIN CRUCIATE LEFT FU

KNEE SPRAIN CRUCIATE RIGHT FU

SPRAIN MCL LEFT INITIAL

SPRAIN MCL RIGHT INITIAL

SPRAIN MCL LEFT FU

SPRAIN MCL RIGHT FU

SPRAIN LCL LEFT INITIAL

SPRAIN LCL RIGHT INITIAL

SPRAIN LCL LEFT FU

SPRAIN LCL RIGHT FU

MEDIAL MENISCUS TEAR LEFT

MEDIAL MENISCUS TEAR RIGHT

LATERAL MENISCUS TEAR LEFT

LATERAL MENISCUS TEAR RIGHT

ACL TEAR LEFT

ACL TEAR RIGHT

POSTERIOR LOWER LEG LEFT STRAIN INITIAL