|
Chief Complaint
|
New Condition
|
|
Follow-Up
|
Acute Onset?
|
|
Date of Accident:
|
Accident Location (street,city,s
|
|
Accident Info:
• • •
|
Were symptoms from gradual onset?
|
|
Attorney Representation
|
|
|
Duration of arm pain
|
Pain location
• • •
|
|
Injury
|
injury description
|
|
Pain Score
• • •
|
Hand dominance
• • •
|
|
Pain description
• • •
|
Pain Progression
• • •
|
|
Radiating pain
• • •
|
Upper extremity N/T/Paresthesias?
• • •
|
|
Upper extremity weakness?
• • •
|
SOB/Trouble breathing
|
|
Past treatments
• • •
|
Imaging
• • •
|
|
Past Surgery
|
Surgery
|
|
EMG/NCS
|
|
