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Chief Complaint
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Chief Complaint
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Location of Pain
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Ask if these additional symptoms are present
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The injury occurred ___ (years/months/days) ago.
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Additional Statements/Complaints
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Gap in seeing doctor/multi pharmacy/High PMP
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Does medication control pain?
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Additional Comments
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History of Present Illness
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History of Present Illness
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Handedness
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Original Injury / Cause of Pain
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Original Cause of Pain (Other)
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New injury/ re-injury
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Original Cause of Pain (Detailed Account)
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Did meds cause re-injury?
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HPI -- Motor Vehicle Accident
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Motor Vehicle Accident
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Patient was Inside a Vehicle
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Patient was a Pedestrian
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Type of Vehicle
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Movement Before Collision
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Details of Collision
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Details of Collision
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Location of Impact
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Position in the Vehicle
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Was patient wearing a seatbelt?
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Was patient braced during impact?
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Body Movement Upon Impact (Description)
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Body Movement Upon Impact (Description)
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Body Movement Upon Impact (Direction)
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Body Movement Upon Impact (Direction)
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Did patient lose consciousness as a result of impact?
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Did patient lose consciousness as a result of impact?
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Did the patient go to the hospital after the accident?
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Was the patient admitted into a hospital after the accident?
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Name of Hospital (If Applicable)
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Name of Hospital (If Applicable)
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Comments
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HPI -- Details of Pain
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Details of Pain
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Nature of Pain
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Nature of Pain (Other)
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Which of the following makes pain worse?
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Which of the following makes pain worse? (Other)
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Which of the following makes pain better?
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Which of the following makes pain better? (Other)
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Pain Level [0-10] (Without Medication)
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Pain Level [0-10] (With Medication)
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How often does patient feel pain?
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When does the pain occur (on a daily basis)?
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Has pain affected patient's mood?
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Has pain affected patient's sleep?
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HPI -- ADL Assessment
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ADL Assessment
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How has pain interfered with patient's normal daily activities?
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Comments
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What normal daily activities are hindered due to the patient's pain?
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Improvement of ADL's
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HPI -- Past Treatments for Pain
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Past Treatments for Pain
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Has the patient been treated by a pain doctor before?
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Past Treatments for Pain
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Past Treatments for Pain (Other) (free text)
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