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Telehealth
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Chief Complaint(s)
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Cervical Spine
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Neck pain Onset
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Neck pain Location
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Neck pain Duration
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Neck pain Characteristics
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Neck pain Severity
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Neck pain Aggravating Factors
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Neck pain Alleviating Factors
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No radiation symptoms
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Radiation description
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Radiation location
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% Neck pain
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% UE pain
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Additional Cervical Spine Comments
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Thoracic Spine
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Mid back pain Onset
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Mid back pain Location
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Mid back pain Duration
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Mid back pain Characteristics
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Mid back pain Severity
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Mid back pain Aggravating Factors
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Mid back pain Alleviating Factors
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No radiation symptoms
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Radiation description
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Radiation location
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Additional Thoracic Spine Comments
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Lumbar Spine
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Low back pain Onset
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Low back pain Location
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Low back pain Duration
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Low back pain Characteristics
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Low back pain Severity
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Low back pain Aggravating Factors
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Low back pain Alleviating Factors
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No radiation symptoms
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Radiation description
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Radiation location
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% Low back pain
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% LE pain
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Additional Lumbar Spine Comments
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No Neurological Deficits
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Neuro Deficits Comments
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Shoulder
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Shoulder pain Onset
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Shoulder pain location
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Shoulder pain Duration
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Shoulder pain Characteristics
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Shoulder pain Severity
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Shoulder pain Aggravating Factors
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Shoulder pain Alleviating Factors
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Shoulder pain Comments
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Knee
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Knee pain Onset
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Knee pain Location
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Knee pain Duration
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Knee pain Characteristics
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Knee pain Severity
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Knee pain Aggravating Factors
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Knee pain Alleviating Factors
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Knee pain Comments
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Treatment
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Pain Medications
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Treatments Tried
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Treatment Duration
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Treatment Benefit
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No injections
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Injections performed
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Injections Benefit
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No surgery intervention
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Spine surgery description
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Spine surgery date
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Additional HPI Comments
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