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FOLLOW-UP/FINAL VISIT TEMPLATE
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Telemedicine
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Reason for Visit:
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History of Present Illness
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Date of Accident
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Reason(s) for Follow-up
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% Improvement Since the Accident
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Comments on HPI (changes since last visit)
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Change in Pain Since Last Visit
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Headache
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Side
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Location
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Radiating
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Intensity
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Timing
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Quality
• • •
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Aggravating factors
• • •
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Alleviating factors
• • •
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Free text
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Chest
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Side
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Radiating
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Intensity
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Timing
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Quality
• • •
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Aggravating factors
• • •
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Alleviating factors
• • •
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Free text
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Abdomen
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Side
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Location
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Intensity
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Timing
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Quality
• • •
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Aggravating factors
• • •
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Alleviating factors
• • •
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Free Text
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Cervical
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Side
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Radiating
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Intensity
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Timing
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Quality
• • •
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Aggravating factors
• • •
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Alleviating factors
• • •
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Free text
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Thoracic
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Side
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Radiating
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Intensity
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Timing
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Quality
• • •
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Aggravating factors
• • •
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Alleviating factors
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Free text
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Lumbar
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Side
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Radiating
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Intensity
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Timing
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Quality
• • •
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Aggravating factors
• • •
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Alleviating factors
• • •
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Free text
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Sacrum
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Side
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Radiating
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Intensity
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Timing
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Quality
• • •
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Aggravating factors
• • •
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Alleviating factors
• • •
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Free text
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Hip
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Side
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Location
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Radiating
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Intensity
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Timing
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Quality
• • •
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Aggravating factors
• • •
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Alleviating factors
• • •
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Free text
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Upper Leg
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Side
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Location
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Radiating
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Intensity
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Timing
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Quality
• • •
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Aggravating factors
• • •
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Alleviating factors
• • •
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Free Text
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Knee
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Side
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Location
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Radiating
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Intensity
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Timing
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Quality
• • •
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Aggravating factors
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Alleviating factors
• • •
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Free text
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Lower Leg
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Side
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Location
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Radiating
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Intensity
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Timing
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Quality
• • •
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Aggravating factors
• • •
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Alleviating factors
• • •
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Free Text
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Foot and Ankle
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Side
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Location
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Radiating
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Intensity
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Timing
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Quality
• • •
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Aggravating factors
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Alleviating factors
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Free text
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Shoulder
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Side
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Radiating
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Intensity
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Timing
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Quality
• • •
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Aggravating factors
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Alleviating factors
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Free Text
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Upper Arm
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Side
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Radiating
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Intensity
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Timing
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Quality
• • •
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Aggravating factors
• • •
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Alleviating factors
• • •
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Free Text
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Elbow
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Side
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Location
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Radiating
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Intensity
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Timing
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Quality
• • •
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Aggravating factors
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Alleviating factors
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Free text
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Forearm
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Side
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Radiating
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Intensity
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Timing
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Quality
• • •
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Aggravating factors
• • •
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Alleviating factors
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Free text
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Hand and Wrist
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Side
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Location
• • •
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Radiating
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Intensity
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Timing
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Quality
• • •
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Aggravating factors
• • •
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Alleviating factors
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Free text
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Review of Systems
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ROS - is Normal (except Musculoskeletal)
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ROS is Abnormal (Fill in Every System)
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ROS - see HPI
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Constitutional
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Comments on Constitutional (optional)
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HEENT
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Comments on Eyes (optional)
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Cardiovascular
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Comments on Cardiovascular (optional)
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Respiratory
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Comments on Respiratory (optional)
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Gastrointestinal
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Comments on Gastrointestinal (optional)
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Genitourinary
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Comments on Genitourinary (optional)
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Neurologic
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Comments on Neurologic (optional)
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Musculoskeletal
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Comments on Musculoskeletal (optional)
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Psychiatric
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Comments on Psychiatric (optional)
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Integumentary
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Comments on Integumentary (optional)
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Allergic
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Comments on Allergic (optional)
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Endocrine
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Comments on Endocrine (optional)
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Past Medical, Family, and Social Hx
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Date of Initial Visit
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Any changes in PMFS History since initial visit?
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If "Yes", list changes to PMFS Hx
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