|
New Patient/New Condition
|
Follow-Up
|
|
Pre-Op
|
MRI Review
|
|
Pre-Op Fields
|
|
|
Body Part (free type)
|
Surgical Procedure (free type)
|
|
Date of Surgery
|
Surgery Location
|
|
Reference Field
|
|
|
MRI Review Fields
|
|
|
Telemedicine
|
Body part(s)
|
|
Imaging Type
|
Imaging Location
|
|
Imaging Location (free-text)
|
Date of Service
|
|
Conditions Being Evaluated
|
Availability of Images/Report
|
|
HPI
|
|
|
HPI
|
|
|
Location of pain
|
Radiating pain location
|
|
Numbness/tingling location
|
Pain score (0-10)
|
|
Positive symptoms
• • •
|
Negative symptoms
• • •
|
|
Additional HPI
|
|
|
HPI
|
|
|
Location of pain
|
Radiating pain location
|
|
Numbness/tingling location
|
Pain score (0-10)
|
|
Positive symptoms
• • •
|
Negative symptoms
• • •
|
|
Medication
|
Denies medications
|
|
Work Status
|
|
|
Additional information
|
|
