Pain History Location: [text] Characterized as: [text]. Radiation: [text] Severity now (0-10): [text] Severity at worst (0-10): [text] Duration and timing: [text] Provocative factors: [text] Palliating factors: [text] Pain beliefs/expectations: Cause: [text size=72 memo=" <-- What is causing my pain?"] Meaning: [text size=72 memo=" <-- Work will worsen my pain because..."] Impact: [text size=72 memo=" <-- On my work/social/recreational/quality of life in general."] Treatment: [text size=72 memo=" <-- What needs to be done now and in the future for my pain."] Goals: [text size=72 memo=" <-- What I expect to achieve with treatment."] Involvement: [text size=72 memo=" <-- How involved will I be in my treatment?"]
There are 14 form elements.
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Sandbox Metrics: Structured Data Index 0, 8 form elements, 102 boilerplate words, 8 text boxes, 8 total clicks
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