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History of Present Illness
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---------- Date of Birth ----------
First Name
Last Name
Month
Day
Year
Gender
January
February
March
April
May
June
July
August
September
October
November
December
1
2
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2024
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2015
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2012
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1904
1903
1902
1901
1900
Male
Female
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Provider Name
Email address for access to Patient Portal:
CHIEF COMPLAINT
Which area is experiencing the greatest pain / problem?
neck
ankle
hip
elbow
shoulder
knee
hand
wrist
foot
back
finger
toe
leg
PAIN
Location of pain:
left
right
both
shoulder
upper arm
elbow
lower arm
wrist
hand
finger
hip
left
right
both
groin
thigh
knee
lower leg
ankle
foot
toes
neck
collar bone
back
pelvis
other (please specify):
Are you currently experiencing pain?
Yes
No
0 = no pain 10 = most severe pain imaginable
0
1
2
3
4
5
6
7
8
9
10
Severity of pain:
Quality of pain:
aching
burning
clicking
dull
instability
locking
numbness
pins / needles
sharp
swelling
tingling
throbbing
Timing of pain (when it started):
in the last week
1-3 months
6-12 months
in the last month
3-6 months
over 1 year
Duration of pain (how long it lasts):
continuous
occasional
at night
other (please specify):
What makes your pain WORSE?
standing
laying down
bending
sitting
walking
running
kneeling
driving
weather
squatting
overhead activities
What makes your pain BETTER?
medication
standing
rest
ice
walking
sitting
massage
heat
exercise
physical therapy
elevation
laying down
TREATMENTS
Which treatment(s) have you had for your current problem?
brace / splint
Did this treatment help?
Yes
No
crutches
Did this treatment help?
Yes
No
elevation
Did this treatment help?
Yes
No
heat
Did this treatment help?
Yes
No
ice
Did this treatment help?
Yes
No
injection
Did this treatment help?
Yes
No
medication
Did this treatment help?
Yes
No
physical therapy
Did this treatment help?
Yes
No
rest
Did this treatment help?
Yes
No
stretching
Did this treatment help?
Yes
No
surgery
Did this treatment help?
Yes
No
None
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