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Alert(s)
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L&I and Auto Claim Next Re-Exam Date
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Date of Onset
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Reason For Visit
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Onset Description
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Changes Since Last Visit
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Area Of Chief Complaint
• • •
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Chief Complaint Description
• • •
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Mechanism
• • •
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Radiating Pain
• • •
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Severity
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Chronology
• • •
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Aggravating Factor
• • •
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TMJ Pain
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Headache Section
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Frequency of Headaches
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Are they increasing in frequency?
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Onset of Each Headache (cont. w/ next question)
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When do they Usually Begin?
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Duration of Headache
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Headaches Prevent Activities
• • •
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Location of Headaches (cont. w/ next question)
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What does the headache feel like?
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Headache Triggers
• • •
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Premonitory Symptoms
• • •
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Aura Symptoms
• • •
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Associated Symptoms
• • •
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Alleviating Factors
• • •
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New Switch
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The DN-4 Questionnaire for Probability of Neuropathic Pain
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Question 1: Does the pain have one or more of the following characteristics?
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Burning
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Painful Cold
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Electric Shock
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Question 2: Is pain associated with one or more of the following symptoms in the same area?
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Tingling
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Pins and needles
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Numbness
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Itching
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Question 3: Is the pain located in an area where the physical exam may reveal one or more characteristics?
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Hypoesthesis to touch
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Hypoesthesia to pinprick
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Question 4: in the painful area, can the pain be caused or Increased by?
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Brushing
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Patient's Score
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