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HPI
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Title (Last Name will populate)
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The patient presents for
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Last evaluated on/ current state.
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On a scale from 1-10, 10 being the worst, the patient rates their pain in the following manner.
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Left shoulder
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The left shoulder pain is a___/10
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The problem has been present since the accident
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The patient has tried treating the pain with
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The pain is described as
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The pain is constant/intermittent
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What makes the pain worse?
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What makes the pain better?
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Limitations
• • •
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Right shoulder
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The right shoulder pain is a___/10
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The problem has been present since the accident
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The patient has tried treating the pain with
• • •
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The pain is described as
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The pain is constant/intermittent
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What makes the pain worse?
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What makes the pain better?
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Limitations
• • •
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Left Elbow
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Left elbow is a___/10
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The problem has been present since the accident
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The patient has tried treating the pain with
• • •
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The pain is described as
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The pain is constant/intermittent
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What makes the pain worse?
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What makes the pain better?
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Limitations
• • •
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Right Elbow
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Right elbow is a___/10
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The problem has been present since the accident
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The patient has tried treating the pain with
• • •
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The pain is described as
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The pain is constant/intermittent
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What makes the pain worse?
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What makes the pain better?
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Limitations
• • •
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Left Wrist
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Left wrist is a___/10
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The problem has been present since the accident
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The patient has tried treating the pain with
• • •
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The pain is described as
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The pain is constant/intermittent
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What makes the pain worse?
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What makes the pain better?
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Limitations
• • •
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Right Wrist
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Right wrist is a___/10
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The problem has been present since the accident
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The patient has tried treating the pain with
• • •
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The pain is described as
• • •
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The pain is constant/intermittent
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What makes the pain worse?
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What makes the pain better?
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Limitations
• • •
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Right Hand
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Right hand is a___/10
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The problem has been present since the accident
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The patient has tried treating the pain with
• • •
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The pain is described as
• • •
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The pain is constant/intermittent
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What makes the pain worse?
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What makes the pain better?
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Limitations
• • •
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Left Hand
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Left hand is a___/10
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The problem has been present since the accident
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The patient has tried treating the pain with
• • •
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The pain is described as
• • •
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The pain is constant/intermittent
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What makes the pain worse?
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What makes the pain better?
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Limitations
• • •
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Left Hip
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Left hip is a___/10
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The problem has been present since the accident
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The patient has tried treating the pain with
• • •
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The pain is described as
• • •
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The pain is constant/intermittent
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What makes the pain worse?
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What makes the pain better?
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Limitations
• • •
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Right Hip
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Right hip is a___/10
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The problem has been present since the accident
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The patient has tried treating the pain with
• • •
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The pain is described as
• • •
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The pain is constant/intermittent
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What makes the pain worse?
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What makes the pain better?
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Limitations
• • •
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Left Knee
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Left knee pain is a___/10
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The problem has been present since the accident
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The patient has tried treating the pain with
• • •
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The pain is described as
• • •
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The pain is constant/intermittent
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What makes the pain worse?
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What makes the pain better?
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Limitations
• • •
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Right Knee
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Right knee pain is a___/10
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The problem has been present since the accident
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The patient has tried treating the pain with
• • •
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The pain is described as
• • •
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The pain is constant/intermittent
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What makes the pain worse?
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What makes the pain better?
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Limitations
• • •
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Right Ankle
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Right ankle is a___/10
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The problem has been present since the accident
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The patient has tried treating the pain with
• • •
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The pain is described as
• • •
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The pain is constant/intermittent
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What makes the pain worse?
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What makes the pain better?
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Limitations
• • •
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Left Ankle
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Left ankle is a___/10
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The problem has been present since the accident
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The patient has tried treating the pain with
• • •
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The pain is described as
• • •
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The pain is constant/intermittent
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What makes the pain worse?
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What makes the pain better?
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Limitations
• • •
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Right Foot
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Right foot is a___/10
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The problem has been present since the accident
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The patient has tried treating the pain with
• • •
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The pain is described as
• • •
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The pain is constant/intermittent
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What makes the pain worse?
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What makes the pain better?
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Limitations
• • •
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Left Foot
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Left foot is a___/10
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The problem has been present since the accident
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The patient has tried treating the pain with
• • •
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The pain is described as
• • •
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The pain is constant/intermittent
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What makes the pain worse?
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What makes the pain better?
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Limitations
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WC
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DOA:
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Employer at time of accident:
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Occupation at the time of the accident:
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Job Duties:
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Currently Working: Yes (FT/ PT) or No
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Date last worked? (type full date with year)
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% of disability
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WC Notes (Add any restrictions or upcoming surgeries/hearings) related to case
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Notes
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Exam:
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ROM
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Right Knee Normal
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Left Knee Normal
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Right Knee Abnormal
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Left Knee Abnormal
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Right Knee Abnormal Severe
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Left Knee Abnormal Severe
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Right Knee: 1st Post-Op Visit Knee Arthroscopy
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Left Knee: 1st Post-Op Visit Knee Arthroscopy
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Right Knee: 2nd Post-Op Visit Knee Arthroscopy
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Left Knee: 2nd Post-Op Visit Knee Arthroscopy
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Right Shoulder Normal
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Left Shoulder Normal
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Right Shoulder Abnormal
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Left Shoulder Abnormal
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Right Shoulder Abnormal Severe
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Left Shoulder Abnormal Severe
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Right Shoulder: 1st Post-Op Visit Shoulder
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Left Shoulder: 1st Post-Op Visit Shoulder
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Right Wrist Normal
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Left Wrist Normal
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Right Wrist Abnormal
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Left Wrist Abnormal
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Right Elbow Normal
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Left Elbow Normal
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Right Elbow Abnormal
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Left Elbow Abnormal
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Right Ankle Normal
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Left Ankle Normal
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Right Ankle Abnormal
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Left Ankle Abnormal
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Right Hip Normal
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Left Hip Normal
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Right Hip Abnormal
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Left Hip Abnormal
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Right Knee Exam Normal
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Left Knee Exam Normal
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Notes
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Notes
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Right Knee Exam Abnormal
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Left Knee Exam Abnormal
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Notes
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Notes
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Right Knee Exam Abnormal Severe
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Left Knee Exam Abnormal Severe
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Notes
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Notes
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Right Knee: 1st Post-Op Knee Arthroscopy
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Left Knee: 1st Post-Op Knee Arthroscopy
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Right Knee: 2nd Post-Op Visit Knee Arthroscopy
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Left Knee: 2nd Post-Op Visit Knee Arthroscopy
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Right Shoulder Exam Normal
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Left Shoulder Exam Normal
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Notes
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Notes
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Right Shoulder Exam Abnormal
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Left Shoulder Exam Abnormal
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Notes
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Notes
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Right Shoulder Exam Abnormal Severe
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Left Shoulder Exam Abnormal Severe
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Notes
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Notes
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Right Shoulder: 1st Post-Op Visit Shoulder
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Left Shoulder: 1st Post-Op Visit Shoulder
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Right Wrist Normal Exam
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Left Wrist Normal Exam
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Notes
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Notes
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Right Wrist Abnormal Exam
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Left Wrist Abnormal Exam
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Notes
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Notes
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Right Elbow Exam Normal
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Left Elbow Normal Exam
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Notes
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Notes
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Right Elbow Abnormal Exam
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Left Elbow Abnormal Exam
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Notes
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Notes
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Right Ankle Normal Exam
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Left Ankle Normal Exam
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Notes
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Notes
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Right Ankle Abnormal Exam
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Left Ankle Abnormal Exam
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Notes
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Notes
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Right Hip Normal Exam
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Left Hip Normal Exam
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Notes
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Notes
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Right Hip Abnormal Exam
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Left Hip Abnormal Exam
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Notes
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Notes
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Allergies
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Allergies
• • •
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Medications
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Medications
• • •
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notes
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Past Medical History
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Past Medical History
• • •
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Notes
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Past Surgical History
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Notes
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Imaging Studies
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Imaging Studies
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Imaging Studies
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Diagnosis:
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RIGHT KNEE
• • •
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LEFT KNEE
• • •
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RIGHT SHOULDER
• • •
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LEFT SHOULDER
• • •
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RIGHT ELBOW
• • •
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LEFT ELBOW
• • •
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RIGHT HIP
• • •
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LEFT HIP
• • •
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RIGHT FOOT
• • •
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LEFT FOOT
• • •
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RIGHT WRIST
• • •
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LEFT WRIST
• • •
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RIGHT ANKLE
• • •
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LEFT ANKLE
• • •
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Counseling: Right Meniscal Tear
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Counseling: Left Meniscal Tear
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Counseling: Right Meniscal Tear
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Counseling: Left Meniscal Tear
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Counseling: Right Knee Arthritis
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Counseling: Left Knee Arthritis
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Counseling: Right Knee Arthritis
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Counseling: Left Knee Arthritis
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Counseling: Right Chondromalacia Patella
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Counseling: Left Chondromalacia Patella
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Counseling: Right Chondromalacia Patella
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Counseling: Left Chondromalacia Patella
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Counseling: Right Biceps Tendinitis
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Counseling: Left Biceps Tendinitis
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Counseling: Right Biceps Tendinitis
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Counseling: Left Biceps Tendinitis
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Counseling: Right Bankart Lesion
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Counseling: Left Bankart Lesion
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Counseling: Right Bankart Lesion
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Counseling: Left Bankart Lesion
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Counseling: Right Labral Tear
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Counseling: Left Labral Tear
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Counseling: Right Labral Tear
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Counseling: Left Labral Tear
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Counseling: Right Calcific Tendinitiis
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Counseling: Left Calcific Tendinitiis
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Counseling: Right Calcific Tendinitiis
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Counseling: Left Calcific Tendinitiis
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Counseling: Right Rotator Cuff Tear
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Counseling: Left Rotator Cuff Tear
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Counseling: Right Rotator Cuff Tear
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Counseling: Left Rotator Cuff Tear
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Counseling: Right AC Arthritis
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Counseling: Left AC Arthritis
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Counseling: Right AC Arthritis
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Counseling: Left AC Arthritis
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Counseling: Right OA Arthritis
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Counseling: Left OA Arthritis
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Counseling: Right OA Arthritis
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Counseling: Left OA Arthritis
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Counseling: Right Adhesive Capsulitis
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Counseling: Left Adhesive Capsulitis
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Counseling: Right Adhesive Capsulitis
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Counseling: Left Adhesive Capsulitis
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Counseling: Right AC Sprain
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Counseling: Left AC Sprain
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Counseling: Right AC Sprain
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Counseling: Left AC Sprain
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Counseling: Right Wrist Tendinitis
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Counseling: Left Wrist Tendinitis
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Counseling: Right Wrist Tendinitis
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Counseling: Left Wrist Tendinitis
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Counseling: Right Carpal Tunnel Syndrome
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Counseling: Left Carpal Tunnel Syndrome
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Counseling: Right Carpal Tunnel Syndrome
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Counseling: Left Carpal Tunnel Syndrome
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Counseling: Right Cubital Tunnel Syndrome
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Counseling: Left Cubital Tunnel Syndrome
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Counseling: Right Cubital Tunnel Syndrome
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Counseling: Left Cubital Tunnel Syndrome
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Counseling: Right Elbow Lateral Epicondylitis
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Counseling: Left Lateral Epicondylitis
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Counseling: Right Lateral Epicondylitis
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Counseling: Lett Lateral Epicondylitis
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Counseling: Right Ankle Sprain
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Counseling: Left Ankle Sprain
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Counseling: Right Ankle Sprain
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Counseling: Left Ankle Sprain
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Counseling: Right Ankle Impingement
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Counseling: Left Ankle Impingement
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Counseling: Right Ankle Impingement
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Counseling: Left Ankle Impingement
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Counseling: Right Trochanteric Bursitis
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Counseling: Left Trochanteric Bursitis
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Counseling: Right Trochanteric Bursitis
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Counseling: Left Trochanteric Bursitis
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Counseling: Right Hip OA
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Counseling: Left Hip OA
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Counseling: Right Hip OA
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Counseling: Left Hip OA
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Counseling: Right Hip Labral Tear
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Counseling: Left Hip Labral Tear
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Counseling: Right Hip Labral Tear
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Counseling: Left Hip Labral Tear
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Counseling: Right Hip Impingement
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Counseling: Left Hip Impingement
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Counseling: Right Hip Impingement
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Counseling: Left Hip Impingement
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Surgery Recommendation:
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Surgery Recommended Not Ordered.
• • •
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Physical Therapy Order
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Indication:
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Instructions:
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Therapeutic Exercises:
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Assistive Device:
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Manual Therapy:
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Modalities:
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notes
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MRI
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notes (body part for MRI) Free Type
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was ordered and will follow up results.
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Order: Surgery Right Knee Arthroscopy
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Order: Surgery Left Knee Arthroscopy
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Order: Surgery Right Knee Arthroscopy
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Order: Surgery Left knee Arthroscopy
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Order: Right Total Knee
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Order: Left Total Knee
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Order: Right Total Knee
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Order: Left Total Knee
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Order: Right Shoulder Arthroscopy RTC Repair
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Order: Left Shoulder Arthroscopy RTC Repair
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Order: Right Shoulder Arthroscopy RTC Repair
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Order: Left Shoulder Arthroscopy RTC Repair
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Order: Right Shoulder Arthroscopy Labral Repair
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Order: Left Shoulder Arthroscopy Labral Repair
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Order: Right Shoulder Arthroscopy Labral Repair
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Order: Left Shoulder Arthroscopy Labral Repair
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Order: Right Total Shoulder
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Order: Left Total Shoulder
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Order: Right Total Shoulder
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Order: Left Total Shoulder
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Order: Right Carpal Tunnel Release
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Order: Left Carpal Tunnel Release
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Order: Right Carpal Tunnel Release
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Order: Left Carpal Tunnel Release
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Order: Vascutherm-5 Cold Compression Therapy
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Causality
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notes
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Jacob
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Magee
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Katsigiorgis
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Bracco
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Bracco
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Porti
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Porti
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Mensah
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Michiel
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Taheri
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Tengco
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Smyth
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Smyth
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