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Chief Complaint
• • •
|
Radiating Pain?
|
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Pain Score
/
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Impact/Injury Severity
• • •
|
|
Loss of Consciousness?
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HISTORY OF PRESENT ILLNESS
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New Reference Field
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Other History
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Chiro/PT Initiated?
• • •
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Failure to Non Narcotic Meds
|
|
MRI Completed?
|
MRI Findings
|
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Neck Pain
|
|
|
Cervical Pain Present?
|
Pain Location
• • •
|
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Pain Intensity
• • •
|
Pain Rating
/
|
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Radiating Pain Destinations
• • •
|
Pain Description
• • •
|
|
Pain Frequency
• • •
|
What makes pain worse?
• • •
|
|
Headaches
|
Numbness Location
• • •
|
|
Cervical Radicular Pain Areas
• • •
|
Facet mediated pain location
• • •
|
|
|
|
|
OLD MACRO - DISREGARD -Numbness Location
|
OLD MACRO- DISREGARD-Facet mediated pain location
|
|
Low Back Pain
|
|
|
Low Back Pain Present?
|
Pain Location
• • •
|
|
Pain Intensity
• • •
|
Pain Description
• • •
|
|
Pain Frequency
• • •
|
What makes pain worse?
• • •
|
|
Bowel/Bladder/Weakness?
• • •
|
Loss of Balance
• • •
|
|
Radiating Pain Destinations
• • •
|
|
|
Lumbar Radicular Pain Areas
• • •
|
Lumbar Facet Mediated Pain Areas
• • •
|
|
Headaches
|
|
|
Headaches Present
|
Pain Radiating
• • •
|
|
Falls/Seizures/Consciousness
• • •
|
|
|
Right vs Left Shoulder Pain
|
|
|
Left Shoulder Pain?
• • •
|
Radiating Pain?
• • •
|
|
L Shoulder Numbness/Tingling?
|
Pain Intensity
• • •
|
|
|
|
|
Right Shoulder Pain?
• • •
|
Radiating Pain?
• • •
|
|
R Shoulder Numbness/Tingling?
|
Pain Intensity
• • •
|
|
Right vs Left Leg Pain
|
|
|
Left Leg Pain?
• • •
|
What makes pain worse?
• • •
|
|
Pain Intensity
• • •
|
|
|
Right Leg Pain?
• • •
|
What makes pain worse?
• • •
|
|
Pain Intensity
• • •
|
|
|
FUNCTIONALS/ADL
|
|
|
Functional/QoL Assessment
• • •
|
|
|
MEDICAL HISTORY
|
|
|
Past Medical History
|
History of Chronic Pain?
|
|
Past Surgical History
|
Medications
|
|
Texas PMP Checked?
• • •
|
On Opioids Chronically?
|
|
Blood Thinners?
|
Allergies?
|
|
Social History
• • •
|
Previous Injuries?
|
