|
Chief Complaint I
|
Chief Complaint
|
|
Duration
|
Duration unit
|
|
Location
|
Onset
• • •
|
|
MOI (use connecting words: since, after, during, etc.)
|
Hx Notes
|
|
Hx Notes - ADL, emotion, etc. (new paragraph)
|
|
|
Previous?
|
If y, addl comments? (n yrs ago doing m. prior Tx) (at least add PUNCTUATION!)
|
|
Hx Notes
|
Progress
|
|
Persistance
|
comments - % of time, frequency, duration (add PUNCTUATION)
|
|
Hx Notes - ADL, emotion, etc. (new paragraph)
|
|
|
Provocative
• • •
|
addl comments (minimum add PUNCTUATION)
|
|
Palliative
• • •
|
addl comments (minimum add PUNCTUATION)
|
|
Quality
• • •
|
additonal comments (at least add PUNCTUATION)
|
|
Radiation upper body
• • •
|
Radiation lower body
• • •
|
|
(radiation) additonal comments (at least add PUNCTUATION)
|
Pt denies Radiation?
|
|
Severity
|
Severity comments / notes
|
|
Time
• • •
|
Activity assc w/ time (previous box) (add PUNCTUATION!)
|
|
Pt denies Temporal?
|
Associated Sx & other Sx
|
|
Chief Complaint I notes
|
Chief Complaint I notes
|
|
Chief Complaint II
|
Chief Complaint
|
|
Duration
|
Duration unit
|
|
Location
|
Onset
• • •
|
|
MOI
|
Hx Notes
|
|
Hx Notes - ADL, emotion, etc. (new paragraph)
|
|
|
Previous?
|
If y, addl comments? (n yrs ago doing m. prior Tx) (Add PUNCTUATION)
|
|
Hx Notes
|
Progress
|
|
Persistance
|
comments - % of time, frequency, duration (add PUNCTUATION)
|
|
Hx Notes - ADL, emotion, etc. (new paragraph)
|
|
|
Provocative
• • •
|
addl comments (minimum add PUNCTUATION)
|
|
Palliative
• • •
|
addl comments (minimum add PUNCTUATION)
|
|
Quality
• • •
|
additonal comments
|
|
Radiation upper body
• • •
|
Radiation lower body
• • •
|
|
(radiation) additonal comments (at least add PUNCTUATION)
|
Pt denies Radiation?
|
|
Severity
|
Severity comments / notes
|
|
Time
• • •
|
Activity assc w/ time (previous box) (add PUNCTUATION!)
|
|
Pt denies temporal?
|
Associated Sx & other Sx
|
|
Chief Complaint II notes
|
Chief Complaint II notes
|
|
Chief Complaint III
|
Chief Complaint
|
|
Duration
|
Duration unit
|
|
Location
|
Onset
• • •
|
|
MOI
|
Hx Notes
|
|
Hx Notes - ADL, emotion, etc. (new paragraph)
|
|
|
Previous?
|
If y, addl comments? (n yrs ago doing m. prior Tx) (add PUNCTUATION!)
|
|
Hx Notes
|
Progress
|
|
Persistance
|
comments - % of time, frequency, duration (Add punctuation)
|
|
Hx Notes - ADL, emotion, etc. (new paragraph)
|
|
|
Provocative
• • •
|
addl comments (minimum add PUNCTUATION)
|
|
Palliative
• • •
|
addl comments (minimum add PUNCTUATION)
|
|
Quality
• • •
|
additional comments
|
|
Radiation upper body
• • •
|
Radiation lower body
• • •
|
|
(radiation) additional comments (at least add PUNCTUATION)
|
Pt denies Radiation?
|
|
Severity
|
Severity comments / notes
|
|
Time
• • •
|
Activity assc w/ time (previous box) (add PUNCTUATION!)
|
|
Pt denies Temporal?
|
Associated Sx & other Sx
|
|
Chief Complaint III notes
|
Chief Complaint III notes
|
|
Additional Complaint 1
|
Hx Notes - ADL, emotion, etc. (new paragraph)
|
|
Additional Complaint 2
|
Hx Notes - ADL, emotion, etc. (new paragraph)
|
|
Health History
|
Health Hx Notes
|
|
Occup or main Daily Activity (use Verb)
|
Main Physical Activities
|
|
Accidents
|
Accidents
|
|
Surgery & Hospitalization Hx includes {{value}}
|
Past surgery/hospital
|
|
Past Medical History includes {{value}}
|
Past medical Hx
|
|
Medication {{value}}
|
Medication
|
|
Diet/Supplements
|
Supplements
|
|
Smoking History (quantity & frequency)
|
Smoking
|
|
Alcohol History (quantity & frequency)
|
Alcohol
|
|
Substance Abuse History
|
Substance Abuse
|
|
Caffeine (type of drink, quantity, frequency)
|
Caffeine
|
|
Past Chiropractic History includes {{value}}
|
Past Chiropractic Hx
|
|
Past Acupuncture History includes {{value}}
|
Past Acupuncture Hx
|
|
Family history
|
Family Hx
|
|
Health Hx Notes
|
Health Hx Notes
|
