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Chief Compliant
• • •
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Free Text CC
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Well Woman Exam
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Well Woman Exam
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LMP (MM/DD/YYYY)
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Patient has menstrual periods?
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Reason why she stopped having a cycle
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Irregular or regular?
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Length of Irregular menstrual cycles
• • •
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Menstraul periods length in days
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Menstrual problems
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Menstrual problem choices
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Duration of symptoms
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Has Seen Provider
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Treatment for Irregular Menstrual periods
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Improvement in symptoms
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Gyn compliants
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Gyn symptoms
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Duration of symptoms
• • •
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Any history of abnormal vaginal bleeding
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Abnormal Bleeding description
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Has Seen Provider
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Breast Compliants?
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Breast Concerns
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Duration of symptoms
• • •
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Has Seen Provider
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GYN History
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Gyn History
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Gravida/Para
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Type of Delivery
• • •
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LMP (MM/DD/YYYY)
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Onset of Menstrual Cycle
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Duration of Cycle
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Last Pap
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History of Abnormal Pap?
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Abnormal Pap of Cervix Choices
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Date of Abnormal Pap Smear
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Treatment of Abnormal Pap Smear
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Any history of pelvic infections
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HX of Infections Choices
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Date of Last Infection
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Partner Treatment
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Sexually active
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Number of Partners
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Male/Female/Both
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Hysterectomy
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Date of hystrectomy
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Reason for Hystrectomy
• • •
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Type of Hystrectomy
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Ovariectomy
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If PT has had ovariectomy, when?
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Breast History
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Recent Mammogram
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Last Mammogram screen
• • •
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History of Breast Cancer/Surgery
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Breast Surgery
• • •
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Date of Procedure
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Family Hx of breast CA
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Family member Breast Cancer
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Previously on HRT
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Hormone Evaluation
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Hormone Symptoms
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Decreased Libido
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Vaginal Dryness
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Poor Sleep
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Mood Swings
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Hot Flashes
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Sweats
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Dry Skin
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Thinning Hair
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Fat Gain
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Immigration physical
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Immigration Physical
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HPI Immigration
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Date of last PE
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PCP
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COVID EXPOSURE
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COVID VACCINATIONS
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Radiology
• • •
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Referrals
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General Instruction Comments
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Problem Gynecological
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Problem Gyn Visit
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HPI Gyn
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Gynecological problem symptoms
• • •
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Duration of symptoms
• • •
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Abdominal/pelvic pain
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Description of Pain
• • •
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Alleviation of symptoms
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Has Seen Provider
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Past Treatment of Pain
• • •
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Provider Follow Up
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Has Seen Provider
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Any history of abnormal vaginal bleeding
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Duration of symptoms
• • •
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Abnormal Bleeding description
• • •
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Has Seen Provider
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Men's Health Evalution
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Men's Health
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Men's HPI
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Past Medical History
• • •
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Past Surgical History
• • •
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Marital Status
• • •
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Sexual Hx
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Alcohol
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Other substances
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Exercise
• • •
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Men reasons for seeking hormone treatment
• • •
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Men Hormone symptoms onset and severity
• • •
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Prostate problems
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Decreased urine flow
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Increased urinary urge
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Metabolic Syndrome/Low Androgens - Male
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Weight gain - chest/hips
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Weight gain - waist
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Decreased libido
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Decreased erection
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Decreased mental sharpness
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Increased forgetfulness
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Decreased muscle size
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Decreased flexibility
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Decreased stamina
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Burned out feeling
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Difficulty sleeping
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Foggy thinking
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Anxious
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Intimate Wellness Visit
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Medical Weight Loss
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Weight Loss Form
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Height
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Weight
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What is your Goal Weight (lbs.)
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When were you last at your Goal Weight (lbs.)
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Why do you want to lose weight?
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Were you overweight as a child
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clothing fit
• • •
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What diets have you tried?
• • •
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Other weight loss methods not listed that you have ? What did you like or dislike about each?
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I snack 2 or More times a day
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I rarely Plan Meals
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Is this the heaviest you've ever been? I
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Date of last PE
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Has a Physician Recommended that you lose weight ?
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Do you exercise?
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What kind of exercise do you do?
• • •
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How often do you exercise?
• • •
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Exercise Frequency per week average
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Exercise Duration average per session
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Family History
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Skin
• • •
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Skin Comments
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Breasts [-]
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Cardiovascular [-]
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Respiratory [-]
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GI [-]
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Urinary [-]
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Genital (Male) [-]
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Periph. Vasc. [-]
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MSK [-]
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Neurological [-]
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Endocrine [-]
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Psychiatric [-]
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ASSESMENT
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Assessment
• • •
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Palliative Care
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Chief Complaint Palliative
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Chief Complaint Pain
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Location of Pain
• • •
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Ask if these additional symptoms are present
• • •
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The injury occurred ___ (years/months/days) ago.
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Additional Statements/Complaints
• • •
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Gap in seeing doctor/multi pharmacy/High PMP
• • •
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Does medication control pain?
• • •
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History of Present Pain Illness
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History of Present Illness Pain
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Handedness
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Original Injury / Cause of Pain
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Original Cause of Pain (Other)
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New injury/ re-injury
• • •
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Original Cause of Pain (Detailed Account)
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Did meds cause re-injury?
• • •
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Motor Vehicle Accident
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HPI -- Motor Vehicle Accident
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Patient was Inside a Vehicle
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Patient was a Pedestrian
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Type of Vehicle
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Movement Before Collision
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Details of Collision
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Details of Collision
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Location of Impact
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Position in the Vehicle
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Was patient wearing a seatbelt?
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Was patient braced during impact?
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Body Movement Upon Impact (Description)
• • •
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Body Movement Upon Impact (Description)
• • •
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Body Movement Upon Impact (Direction)
• • •
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Did patient lose consciousness as a result of impact?
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Did patient lose consciousness as a result of impact?
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Did the patient go to the hospital after the accident?
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Was the patient admitted into a hospital after the accident?
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Details of Pain
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HPI -- Details of Pain
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Nature of Pain
• • •
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Nature of Pain (Other)
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Body Movement Upon Impact (Direction)
• • •
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Which of the following makes pain worse?
• • •
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Which of the following makes pain worse? (Other)
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Which of the following makes pain better?
• • •
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Which of the following makes pain better? (Other)
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Pain Level [0-10] (Without Medication)
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Pain Level [0-10] (With Medication)
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How often does patient feel pain?
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When does the pain occur (on a daily basis)?
• • •
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Has pain affected patient's mood?
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Has pain affected patient's sleep?
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ADL Assessment
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HPI -- ADL Assessment
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How has pain interfered with patient's normal daily activities?
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Comments
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What normal daily activities are hindered due to the patient's pain?
• • •
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Improvement of ADL's
• • •
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Past Treatments for Pain
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HPI -- Past Treatments for Pain
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Has the patient been treated by a pain doctor before?
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Past Treatments for Pain
• • •
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Past Treatments for Pain (Other) (free text)
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Does medication control pain?
• • •
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Medication Modification
• • •
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