|
New patient
|
F/U
|
|
Est pt/new problem
|
|
|
PCP
|
RHD/LHD
|
|
Knee complaint
• • •
|
Associated CC
• • •
|
|
DOI/onset of pain
• • •
|
DOI Comment
|
|
Specific injury [+]
|
Specific injury [-]
|
|
MOI [+]
• • •
|
MOI comment
|
|
Result of MOI
• • •
|
|
|
Exacerbations [+]
• • •
|
Exacerbation comment
|
|
Alleviating factors [+]
• • •
|
Alleviating factors comments
|
|
Onset/Timing
|
|
|
Severity
|
Severity scale
• • •
|
|
Nature of pain
• • •
|
|
|
NIght time pain [+]
|
Nightime pain [-]
|
|
Swelling [-]
|
Swelling [+]
|
|
Instability [-]
|
Instability [+]
|
|
Giving Way [-]
|
Giving Way [+]
|
|
Previous treatment [-]
|
Previous treatment [+]
• • •
|
|
Previous treatment results
|
Previous treatment comments
|
|
Limitation [-]
|
Limitation [+]
• • •
|
|
Pt localize pain [-]
|
Pt localize pain [+]
• • •
|
|
Pt localize pain comment
|
|
