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The patient is a {{age}} year old male/female
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with onset ____
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___ ago
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The patient denies prior injury
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onset of pain coincided with injury when he/she
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The patient describes {{his_or_her}} pain as___
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pain that is {{value}} in nature
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It is exacerbated by ____
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It is relieved by____
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The pain is rated at #/10 in intensity at presen
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with a range of #/10
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to #/10
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Evaluation to date for this complaint has includ
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Testing has included ____
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Treatment to date has included_____
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Comments
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Symptomatic improvement has occurred with____
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Due to the____
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of pain/limitation of motion/numbness
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Location
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radiation
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Quality
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Location Comments
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Severity
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Quality Comments
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Duration
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Severity Comments
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Onset / Timing
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Duration Comments
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Context
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Onset Comments
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Modifying Factors
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Context Comments
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Associated Symptoms
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Modifying Factors Comments
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Previous Treatment
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Associated Symptoms Comments
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