|
New Patient
|
Established Patient
|
|
Reason/s for Visit (What brings you into the office today?) *list all complaints*
• • •
|
|
|
HPI #1
|
|
|
"Initial/New": CC/HPI
|
|
|
CC (What type of pain or condition brings you into the office?)
• • •
|
|
|
CC: (also presents with complaint of __)
|
|
|
LOCATION (Where is the pain/condition located?)
|
|
|
LOCATION: Comments (__same line/blank__)
|
|
|
DURATION (When did you first notice this condition/When did this condition begin?)
|
|
|
DURATION: (__new line__)
|
|
|
TRAUMA (Was there any trauma to the area that may have caused this condition?)
• • •
|
|
|
ONSET: (___new line___)
|
|
|
If yes TRAUMA, (What kind of trauma?)
• • •
|
TRAUMA: (__new line__)
|
|
QUALITY
|
|
|
NATURE (How would you describe your pain?)
• • •
|
|
|
NATURE: (__new line__)
|
|
|
When does the pain feels the worst/What causes the pain to worsen?
• • •
|
|
|
WORST PAIN: (__new line__)
|
|
|
ASSOCIATED SYMPTOMS (Do you have any other symptoms besides pain?)
|
|
|
What other associated symptoms to the pain do you have?
• • •
|
|
|
ASSOCIATED SYMPTOMS: (_new line_)
|
|
|
Weight Bearing ADL's
|
|
|
Weight Bearing ADL's: Walking
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Weight Bearing ADL's: Standing
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Weight Bearing ADL's: Running
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Weight Bearing ADL's: Prolonged Sitting
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Weight Bearing ADL's: Driving
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Weight Bearing ADL's: Computer Work
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Weight Bearing ADL's: Exercising
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Weight Bearing ADL's: Neck Movements
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Weight Bearing ADL's: Upper Extremity Activities
|
|
|
Upper Extremity Activities: Gripping and Grasping
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Upper Extremity Activities: Shoulder Movements
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Attempted Treatment
|
|
|
SELF Therapy/Treatment: (Have you been doing any at home or self treatments?)
|
|
|
If YES, Self Therapy/Treatment
• • •
|
SELF THERAPY: (reports attempted self treatment of _new line_)
|
|
1) Medical Treatment
|
|
|
MEDICAL Treatment (Have you seen any other doctor or specialist for this problem?)
|
|
|
If YES, (Type of Doctor)
• • •
|
MEDICAL TREATMENT: (__new line__)
|
|
Treatments: (What were you treated with when seeing a different doctor/specialist?)
• • •
|
|
|
Attempted Medical Treatments (include; _new line_)
|
|
|
ADVANCED STUDIES/LABS (Were any labs or studies performed?)
|
|
|
Advanced Studies/Labs: (What type of labs or studies were taken?)
• • •
|
|
|
ADVANCED STUDIES: Comments (__new line__)
|
|
|
FINDINGS: Labs/Studies (findings reveal; __new line__)
|
|
|
2) Medical Treatment
|
|
|
MEDICAL Treatment (Have you seen any other doctor or specialist for this problem?)
|
|
|
If YES, (Type of Doctor)
• • •
|
MEDICAL TREATMENT: (__new line__)
|
|
Treatments: (What were you treated with when seeing a different doctor/specialist?)
• • •
|
|
|
Attempted Medical Treatments (include; _new line_)
|
|
|
ADVANCED STUDIES/LABS (Were any labs or studies performed?)
|
|
|
Advanced Studies/Labs: (What type of labs or studies were taken?)
• • •
|
|
|
ADVANCED STUDIES: Comments (__new line__)
|
|
|
FINDINGS: Labs/Studies (findings reveal; __new line__)
|
|
|
3) Medical Treatment
|
|
|
MEDICAL Treatment (Have you seen any other doctor or specialist for this problem?)
|
|
|
If YES, (Type of Doctor)
• • •
|
MEDICAL TREATMENT: (__new line__)
|
|
Treatments: (What were you treated with when seeing a different doctor/specialist?)
• • •
|
|
|
Attempted Medical Treatments (include; _new line_)
|
|
|
ADVANCED STUDIES/LABS (Were any labs or studies performed?)
|
|
|
Advanced Studies/Labs: (What type of labs or studies were taken?)
• • •
|
|
|
ADVANCED STUDIES: Comments (__new line__)
|
|
|
FINDINGS: Labs/Studies (findings reveal; __new line__)
|
|
|
PAST/PREVIOUS Condition (Have you had this or similar condition in the past?)
|
|
|
Previous Treatments (Was it on the same location? Was is healed when treated?)
• • •
|
|
|
"Follow-Up": CC/HPI
|
|
|
Diagnosis: (Condition being evaluated today)
• • •
|
|
|
HPI: Comments (Patient also presents for __)
|
|
|
COURSE (How would you describe the progress of your condition since last visit?)
|
|
|
COURSE: current line of treatment consisting of; NEW LINE(__procedure__ was/was not helpful__)
|
|
|
Current Treatment Plan (Patient continues with; __new line__)
• • •
|
|
|
Current Treatment Plan Comments (Patient admits to not adhering to; (__new line__)
|
|
|
QUALITY
|
|
|
NATURE (How would you describe the nature of your current pain?)
• • •
|
|
|
NATURE: (__blank__)
|
|
|
When does the pain feels the worst/What causes the pain to worsen?
• • •
|
|
|
WORST PAIN: (__new line__)
|
|
|
ASSOCIATED SYMPTOMS (Do you have any other symptoms besides pain?)
|
|
|
What other associated symptoms to the pain do you have?
• • •
|
|
|
ASSOCIATED SYMPTOMS: (__new line__)
|
|
|
Weight Bearing ADL's
|
|
|
Weight Bearing ADL's: Walking
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Weight Bearing ADL's: Standing
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Weight Bearing ADL's: Running
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Weight Bearing ADL's: Prolonged Sitting
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Weight Bearing ADL's: Driving
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Weight Bearing ADL's: Computer Work
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Weight Bearing ADL's: Exercising
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Weight Bearing ADL's: Neck Movements
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Weight Bearing ADL's: Upper Extremity Activities
|
|
|
Upper Extremity Activities: Gripping and Grasping
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Upper Extremity Activities: Shoulder Movements
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
MEDICAL Treatment (Have you been seeking treatment from any other doctor or specialist?)
|
|
|
If YES, (Type of Doctor)
• • •
|
MEDICAL TREATMENT: (__new line__)
|
|
Treatments: (What were you treated with when seeing a different doctor/specialist?)
• • •
|
|
|
Attempted Medical Treatments (include; _new line_)
|
|
|
ADVANCED STUDIES/LABS (Were any labs or studies performed?)
|
|
|
Advanced Studies/Labs: (What type of labs or studies were taken?)
• • •
|
|
|
ADVANCED STUDIES: Comments (__new line__)
|
FINDINGS: Labs/Studies (findings reveal; __new line__)
|
|
HPI #2
|
|
|
"Initial/New": CC/HPI
|
|
|
CC (What type of pain or condition brings you into the office?)
• • •
|
CC: (also presents with complaint of __)
|
|
LOCATION (Where is the pain/condition located?)
|
|
|
LOCATION: Comments (__same line/blank__)
|
|
|
DURATION (When did you first notice this condition/When did this condition begin?)
|
DURATION: (__new line__)
|
|
TRAUMA (Was there any trauma to the area that may have caused this condition?)
• • •
|
ONSET: (___new line___)
|
|
If yes TRAUMA, (What kind of trauma?)
• • •
|
TRAUMA: (__new line__)
|
|
QUALITY
|
|
|
NATURE (How would you describe your pain?)
• • •
|
|
|
NATURE: (__new line__)
|
|
|
When does the pain feels the worst/What causes the pain to worsen?
• • •
|
|
|
WORST PAIN: (__new line__)
|
|
|
ASSOCIATED SYMPTOMS (Do you have any other symptoms besides pain?)
|
|
|
What other associated symptoms to the pain do you have?
• • •
|
|
|
ASSOCIATED SYMPTOMS: (_new line_)
|
|
|
Weight Bearing ADL's
|
|
|
Weight Bearing ADL's: Walking
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Weight Bearing ADL's: Standing
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Weight Bearing ADL's: Running
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Weight Bearing ADL's: Prolonged Sitting
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Weight Bearing ADL's: Driving
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Weight Bearing ADL's: Computer Work
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"1 Hour" pain rating on a scale from 1 to 10?
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Weight Bearing ADL's: Exercising
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Weight Bearing ADL's: Neck Movements
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Weight Bearing ADL's: Upper Extremity Activities
|
|
|
Upper Extremity Activities: Gripping and Grasping
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Upper Extremity Activities: Shoulder Movements
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
"Follow-Up": CC/HPI
|
|
|
Diagnosis: (Condition being evaluated today)
• • •
|
|
|
HPI: Comments (Patient also presents for __)
|
|
|
COURSE (How would you describe the progress of your condition since last visit?)
|
|
|
COURSE: current line of treatment consisting of; NEW LINE(__procedure__ was/was not helpful__)
|
|
|
Current Treatment Plan (Patient continues with; __new line__)
• • •
|
|
|
Current Treatment Plan Comments (Patient admits to not adhering to; (__new line__)
|
|
|
QUALITY
|
|
|
NATURE (How would you describe the nature of your current pain?)
• • •
|
|
|
NATURE: (__blank__)
|
|
|
When does the pain feels the worst/What causes the pain to worsen?
• • •
|
|
|
WORST PAIN: (__new line__)
|
|
|
ASSOCIATED SYMPTOMS (Do you have any other symptoms besides pain?)
|
|
|
What other associated symptoms to the pain do you have?
• • •
|
|
|
ASSOCIATED SYMPTOMS: (__new line__)
|
|
|
Weight Bearing ADL's
|
|
|
Weight Bearing ADL's: Walking
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Weight Bearing ADL's: Standing
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Weight Bearing ADL's: Running
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Weight Bearing ADL's: Prolonged Sitting
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"2 Hours" pain rating on a scale from 1 to 10?
|
|
Weight Bearing ADL's: Driving
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Weight Bearing ADL's: Computer Work
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Weight Bearing ADL's: Exercising
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Weight Bearing ADL's: Neck Movements
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Weight Bearing ADL's: Upper Extremity Activities
|
|
|
Upper Extremity Activities: Gripping and Grasping
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
Upper Extremity Activities: Shoulder Movements
|
|
|
"10 Minutes" pain rating on a scale from 1 to 10?
|
"15 Minutes" pain rating on a scale from 1 to 10?
|
|
"30 Minutes" pain rating on a scale from 1 to 10?
|
"1 Hour" pain rating on a scale from 1 to 10?
|
|
"2 Hours" pain rating on a scale from 1 to 10?
|
"End of the Day" pain rating on a scale from 1 to 10?
|
|
MEDICAL Treatment (Have you been seeking treatment from any other doctor or specialist?)
|
|
|
If YES, (Type of Doctor)
• • •
|
MEDICAL TREATMENT: (__new line__)
|
|
Treatments: (What were you treated with when seeing a different doctor/specialist?)
• • •
|
|
|
Attempted Medical Treatments (include; _new line_)
|
|
|
ADVANCED STUDIES/LABS (Were any labs or studies performed?)
|
|
|
Advanced Studies/Labs: (What type of labs or studies were taken?)
• • •
|
|
|
ADVANCED STUDIES: Comments (__new line__)
|
FINDINGS: Labs/Studies (findings reveal; __new line__)
|
|
HPI #3
|
|
