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Date of Injury:
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Chief Complaint:
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Other:
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Motor vehicle accident
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Position in Car and Where it Was Struck
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Other type of injury
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Other:
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What happened during the claimant's fall?
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Other:
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The claimant (went to the ER, urgent care etc)
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When did the claimant seek treatment?
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History of Inujry
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Medical records reviewed
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The claimant describes the pain as
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Other:
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The claimant states the pain is associated with
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Other:
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The pain rated at best
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The pain rated at worst
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Is the pain constant?
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The pain is made worse with
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Other:
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Does anything make the pain better?
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The pain is made better with
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Other:
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Bowel or bladder neurogenic type changes
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Other:
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Paresthesias?
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Comments
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Paresthesias?
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Location of paresthesias back and upper extremity
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Location of paresthesias right lower extremity
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Location of paresthesias left lower extremity
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Radiating pain?
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Comments
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Location of radiating pain back and upper extremity
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New Short Text Field
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Location of radiating pain right lower extremity
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Location of radiating pain left lower extremity
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Weakness?
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Weakness location
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Comments
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MAY GO TO SPECIFIC BODY PARTS FOR MORE INFO OR CONTINUE BELOW
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IF ADDING SPECIFIC BODY PARTS THEN USE PAST TREATMENT AFTER
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AND SKIP THE NEXT PART
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Has the pain improved worsened stayed the same
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Has the claimant seen other physicians
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New Short Text Field
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Medications
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Has medication helped?
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Medications still used
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Currently in therapy?
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Is therapy helping/has it helped
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Pain persists
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Injection?
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Type of injection
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Did the injections help?
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Did the injection wear off
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Comments
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Surgery for this injury?
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Types of surgery
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Did the surgery help?
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Comments
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Surgery prior to this injury?
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Types of surgery
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Did the surgery help?
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Comments
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Prior injury?
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Prior injury
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How has this injury affected the prior injury?
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New Short Text Field
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Very few records are available for review.
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Medical records reviewed or none available.
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