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HPI
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Chief Complaint
• • •
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Date Pain Started
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Pain Location
• • •
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Pain Description
• • •
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What relieves the pain?
• • •
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What aggravates the pain?
• • •
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Pain Score (At Best)
/
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Pain Score (At Worst)
/
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Pain Score (Average)
/
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Functions Pt Cannot Perform
• • •
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Other Providers Seen
• • •
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Numbness/Tingling/Bowel/Bladder/Fever
• • •
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Additional Information
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PHYSICAL EXAMS
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Cervical
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Cervical Exam Performed?
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Posture
• • •
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Tender?
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Cervical Flexion
• • •
|
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Cervical Extension
• • •
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Cervical Rotation
• • •
|
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Cervical Lateral Flexion
• • •
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Spurling's
• • •
|
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Axial Compression Test
• • •
|
|
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Lumbar
|
|
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Lumbar MSK/Spine Exam Performed?
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TTP
• • •
|
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Slump
• • •
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Straight Leg Raise
• • •
|
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Faber
• • •
|
Hamstring Tightness
• • •
|
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Lumbar Flexion
• • •
|
Lumbar Extension
• • •
|
|
Facet Challenge
• • •
|
|
|
SI Joint
|
|
|
SI Joint Exam Performed?
|
Faber
• • •
|
|
Gaenslens
• • •
|
Iliac Compression Test
• • •
|
|
Sacral Thrust
• • •
|
Thigh Thrust
• • •
|
|
ASSESSMENT
|
|
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Objective Findings
• • •
|
|
|
DIAGNOSIS/IMPRESSION
|
|
|
Cervical Radiculopathy
|
Cervical Disc Herniation
|
|
Cervical Degenerative Disc Disease
|
Cervical Stenosis
|
|
Myofascial Pain
|
|
|
Lumbar Radiculopathy
|
Lumbar Disc Herniation
|
|
Lumbar Degenerative Disc Disease
|
Lumbar Facet Arthropathy
|
|
Sacroiliac Joint Pain
|
|
|
COMMENTARY/DECISION MAKING
|
|
|
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Additional Notes/Comments
|
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RECOMMENDATIONS
|
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Reviewed Imaging
|
Therapy Recommendation
• • •
|
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Diagnostic Purposes
• • •
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Medication (in-progress)
• • •
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Recs If Pain Doesn't Improve
• • •
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