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COVID-19 / TELEMEDICINE
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COVID-19 / PHONE VISIT
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Referral Source
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Self-referred
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PCP
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General HPI Comments
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Symptoms onset (date)
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Symptom Onset (timing)
• • •
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Symptom MOI
• • •
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Onset/MOI Comments
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CERVICAL SYMPTOMS
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Cervical/UE Location
• • •
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Location Comments
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Dermatomal distribution?
• • •
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Nondermatomal distribution?
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Neck vs Arm
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THORACIC SYMPTOMS
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Thoracic Location
• • •
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Location Comments
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LUMBOSACRAL SYMPTOMS
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Lumbar/LE Location
• • •
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Location Comments
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Dermatomal distribution?
• • •
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Nondermatomal distribution?
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Back vs Leg
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PELVIC PAIN
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Pelvic location
• • •
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Location Comments
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Quality
• • •
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Quality Comments
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Current Severity
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Worst Severity
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Severity Comments
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Duration
• • •
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Duration Comments
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Aggravating Factors
• • •
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Aggravating Factors Comments
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Alleviating Factors
• • •
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Alleviating Factors Comments
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CRPS Symptoms?
• • •
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General Symptom Comments
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Associated Symptoms Quicklist
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Urinary Incont
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Fecal Incont
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Saddle
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Radic
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Weakness
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N/T
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Associated Symptoms Comments
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Stenosis Symptoms?
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Stenosis/Ambulation Distance
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Stenosis/Walking/Back or leg pain?
• • •
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Stenosis/Sitting helps?
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Stenosis/Shopping Cart?
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Other/past specialists seen
• • •
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Prior Specialists Comments
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Prior Treatments
• • •
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Prior Treatment Effectiveness
• • •
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Length of prior PT
• • •
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Prior PT Comments
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Prior Medications
• • •
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Prior Medication Comments
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Prior Treatment Comments
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Spine Surgery Hx
• • •
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Spine surgery comments
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Better/Worse/Same
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QoL Impact
• • •
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Other HPI Comments
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Presents with MRI...
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Procedure Date
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