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Date of Injury:
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Chief Complaint:
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Other:
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Motor vehicle accident
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Other:
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Position in Car and Where it Was Struck
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Other:
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Other type of injury
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Other
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Additional other injury information
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Other
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Emergency Room
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The patient was seen
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Comments
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Medical records/chart reviewed
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Referred from?
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Name of referral source
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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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Is the pain constant?
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Comments
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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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Medications
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Has medication helped?
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Medications still used
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Bowel or bladder neurogenic type changes
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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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Comments
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Paresthesias?
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Type of paresthesias?
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Comments
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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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Comments
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Weakness?
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Weakness location
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Comments
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MAY GO TO SPECIFIC BODY PARTS FOR MORE INFO OR CONTINUE BELOW
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IF ADDING SPECIFIC BODY PARTS THEN USE PAST TREATMENT AFTER
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AND SKIP THE NEXT PART
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Has the pain improved worsened stayed the same
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Has the patient seen other physicians
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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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Has the patient had injections?
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Type of injection
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Did the injections help?
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Did the injection wear off
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Comments
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Has the patient had surgery for this injury?
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Did the surgery help?
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Types of surgery
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Comments
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Right hand dominant is YES left is NO
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Has the patient had a prior similar injury?
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Prior injury information
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What type of injury was it?
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How has this injury affected the prior injury?
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New Short Text Field
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Did the patient have surgery for the prior injury?
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Types of surgery
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Did the surgery help?
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Comments
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Chart review macro
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Complete chart review macro
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Available medical records reviewed
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New Patient
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History and Physical
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Consent for SX
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MRI images
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In office photo
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