|
Follow up visit
|
|
|
Follow up
• • •
|
HPI
|
|
Meds refill
|
|
|
current meds
• • •
|
effectiveness
• • •
|
|
compliant with meds intake
|
analgesia
|
|
aberrant behavior
|
PDMP reviewed
|
|
UDx review
|
|
|
New Patient
|
New Patient HPI
|
|
Personal Injury
|
Attorney Representation
|
|
Date of Injury
|
How impact occurred
|
|
Seat belts
|
Loss of conciousness
|
|
Pain onset
• • •
|
Pain onset Comments
|
|
Location
• • •
|
Location Comments
|
|
Duration
• • •
|
Duration Comments
|
|
Quality
• • •
|
Quality Comments
|
|
Severity
|
Severity Comments
|
|
Aggravating factors
• • •
|
Aggravating Factors Comments
|
|
Relieving factors
• • •
|
Relieving Factors Comments
|
|
Associated Symptoms
• • •
|
Associated Symptoms Comments
|
|
|
New Free Draw
|
|
Additional Issues [+]
|
|
|
Numbness/Tingling?
|
Sitting
|
|
Radiating Pain?
|
Standing
|
|
Walking
|
Twisting
|
|
Laying Down
|
Bending Forward
|
|
Bowel/Bladder Dysfunction?
|
Awakened by Pain?
|
|
Patient Concerns
• • •
|
Concerns Comments
|
