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Patient Intake & History
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Patient Intake & History
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Patient Intake & History
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Patient Intake & History
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Subjective
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Subjective Complaint
• • •
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Other
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Patient Medical History
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Past Medical History Freewrite
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Past Surgical History
• • •
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Past Surgical History Freewrite
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Social History
• • •
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Medications
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Allergies
• • •
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Other
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Family has a history of the following
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Family HX
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Review of systems
• • •
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ROS other
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Patient Height
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Patient Weight
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General Wellness Assessment
• • •
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Other
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Objective Findings
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Lower Extremity Image 1
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Lower Extremity Image 2
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Lower Extremity Image 3
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Lower Extremity Image 4
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Image of Bottom of Both Feet
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Gait Analysis
• • •
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Other
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Muskuloskeletal
• • •
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Other
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Vascular
• • •
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Other
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Dermatologic- Skin Exam
• • •
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Other
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Neurologic
• • •
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Other
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Subjective Additional
• • •
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Additional Imaging Reviewed
• • •
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Other
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Assessment
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Assessment/ Diagnoses
• • •
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Assessment/ Diagnoses
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Plan
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Rendered Services
• • •
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Treatment Plan
• • •
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Conservative Treatment Measures
• • •
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Follow-up
• • •
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