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Chief Complaint
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Chief Complaint
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Location of Pain
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Additional Symptoms
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Additional Complaints
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Medication Modification
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Additional 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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Aggravating Factors
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Which of the following makes pain worse? (Other)
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Alleviating Factors
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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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Frequency of Pain
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Occurrence of Pain
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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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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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Did you see another pain doctor?
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Why did you see another doctor?
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Comments
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