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NOT FOR INJECTION FOLLOW UP... USE FOLLOW UP OR INJECTION FOLLOW UP
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Date of Injury:
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Referred from? (if new to RDS)
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Second opinion
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Chief Complaints
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Other
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Comments
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Motor vehicle accident
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Position in Car and Where it Was Struck
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Other type of injury follow up
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Comments
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Medical records/chart reviewed
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Has the pain improved worsened stayed the same
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The patient describes the pain as
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Other:
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The patient states the pain is associated with
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Other:
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The pain rated at best
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The pain rated at worst
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The pain is made worse with
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Other:
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Does anything make the pain better?
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The pain is made better with
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Other:
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Is the paint constant?
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Other:
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Other:
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Radiating pain?
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Location of radiating pain back and upper extremity
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Comments
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Location of radiating pain right lower extremity
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Location of radiating pain left lower extremity
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Paresthesias?
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Location of paresthesias RIGHT upper extremity
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Location of paresthesias LEFT upper extremity
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Location of paresthesias right lower extremity
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Location of paresthesias left lower extremity
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Weakness?
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Weakness location
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Comments
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Medications
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Comments
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Has medication helped?
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Medications still used
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New Short Text Field
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Currently in therapy?
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Is therapy helping/has it helped
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Pain persists
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ALSO SEE INJECTION TREATMENT FOLLOW UP
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Has the patient had injections?
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Type of injection
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How was the pain after the injection?
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Did the injection work for a short time in the shoulder?
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Did the shoulder injection work for a short time in the neck?
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Did the injection work for a short time (generic)?
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Did the injection wear off
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Comments
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Chart review macro
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Complete chart and record review macro
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CFOAS SURGICAL CONSENT PKT
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History and Physical
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MRI/Xray Images
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In office image
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