|
Telemed
|
Referring Physician
|
|
CC:
|
|
|
Radiates
• • •
|
Radiation Comments
|
|
Which Side Is Worse
• • •
|
Laterality Comments
|
|
Description of Pain
• • •
|
Description of Pain Other
|
|
Severity on average
|
Severity Comments
|
|
Onset / Timing
• • •
|
Onset Comments
|
|
Frequency
• • •
|
Frequency Comments
|
|
Duration
• • •
|
Duration Comments
|
|
What makes pain worse
• • •
|
What makes pain worse
|
|
What makes it better
• • •
|
Improvements Comments
|
|
Functional Impact
• • •
|
Associated Symptoms Comments
|
|
Similar pain symptoms in past?
• • •
|
Accident Information:
|
|
Red Flag Symptoms
|
Radiculpathy
• • •
|
|
Prior Treatment and Response (Conservative Care)
|
|
|
Activity modification / Home exercise program
|
|
|
Physical Therapy
|
PT Response
• • •
|
|
Chiropractic Care
|
Chiro reponse
• • •
|
|
Medications
|
Med Response
• • •
|
|
Past Treatment Comments:
|
|
|
Imaging Results
|
|
|
Imaging Results
|
|
