Pain Management Exam

GENERAL: [checkbox name="variable_1" value=" Well nourished|Obese|Thin|Frail|Cachectic|Well Groomed|Unkempt|No visible signs of withdrawal noted|NAD|Appears to be in distress secondary to pain|Anxious|Lethargic|Tearful|Alert|Cooperative|Conversant"][text name="variable_1" default=", "]
EYES: [checkbox name="variable_2" value=" Lids Normal|Conjunctiva Normal|PERRL|EOMI|Glasses|No Glasses|Poor Vision|Blindness|No Blindness|No red eye|No Discharge"][text name="variable_2" default=", "]
ENT: [checkbox name="variable_3" value=" Hearing Aides|No Hearing Aides|Decreased Hearing|No Decreased Hearing|Oral Mucosa Moist|Oral Mucosa Dry|Poor Dentition|Edentulous|Dentures|No Dentures|Decreased dentition"][text name="variable_3" default=", "]
RESP: [checkbox name="variable_4" value=" Normal Effort|Labored Breathing|Tachypnea|Hypopnea|Apnea|Auscultation Clear|Rales/Rhonci|Wheezes|Decreased Breath Sounds|DOE|No increased WOB|No rhonchi/rales/wheezing"][text name="variable_4" default=", "]
CVS: [checkbox name="variable_5" value=" HR Normal|Tachycardia|Bradycardia|Regular Rhythm|Irregular Rhythm|Murmur|No Murmur|Pacemaker|No Pacemaker|Bilateral Pedal Edema|Right Pedal Edema|Left Pedal Edema|Bilateral Pedal Edema (R>L)|Bilateral Pedal Edema (L>R)|No Pedal Edema|Pedal Pulses 2+ bilaterally|Pedal Pulses Decreased Bilaterally"][text name="variable_5" default=", "]
GI: [checkbox name="variable_6" value=" BS Normal|BS Hypotonic|BS Hypertonic|BS Absent|Tenderness|No Tenderness|Mass|No Mass"][text name="variable_6" default=", "]
PSYCH: [checkbox name="variable_7" value=" Alert|Oriented to Person|Oriented to Person/Place|Oriented x3|Confused|Flat|Cooperative|Distrustful|Conversant|Delusional|Agitated|Lethargic|Unresponsive"][text name="variable_7" default=", "]
SKIN: [checkbox name="variable_8" value=" Rash|No rash visible on exposed skin|Dermatitis|No dermatitis|Wound|No Wound|Infection|No Infection|Atypical Lesion|Bruises|Hemosiderin deposits|Venous stasis"][text name="variable_8" default=", "]Musculoskeletal
Posture: [checkbox name="variable_9" value="Head tilt right|Head tilt left|No head tilt|Head rotation right|Head rotation left|No head rotation|Elevated left shoulder|Elevated right shoulder|Elevated left hip|Elevated right hip|Spine kyphotic"]
Tenderness to palpation: [text name="variable_9" default=" "]
Muscle atrophy/decreased strength: [text name="variable_10" default=" "]
Active Range of motion: [checkbox name="variable_10" value="Cervical ROM WNL|Pain with cervical ROM|Decreased cervical flexion|Decreased cervical extension|Thoracic ROM WNL|Pain with thoracic ROM|Decreased thoracic flexion|Decreased thoracic extension|Lumbar ROM WNL|Pain with lumbar ROM|Decreased lumbar flexion|Decreased lumbar extension"][text name="variable_11" default=" "]
Ambulation: [checkbox name="variable_11" value="Normal|Impaired|Needs assistance|Walker|Wheelchair bound|Cane"]
[text name="variable_12" default=" "]
Gait: [checkbox name="variable_12" value="Normal|Visible limp|Walks toes in|Walks toes out|Heel walk left|Heel walk right|Toe walk left|Toe walk right|Shuffling gait"][text name="variable_13" default=" "]
Other:[text name="variable_14" default=" "]
[checkbox name="variable_13" value=" CN's Intact|Sensation Intact|Decreased Sensation|Tremors|No Tremors|Increased Tone"][text name="variable_15" default=", "]
Romberg test: [checkbox name="variable_14" value="Unable to perform due to physical limitations|Patient is unable to maintain balance with their eyes closed|Patient able to maintain balance for  seconds."] 
SKIN: Musculoskeletal
Tenderness to palpation:
Muscle atrophy/decreased strength:
Active Range of motion:


Romberg test:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.48, 29 form elements, 27 boilerplate words, 15 text boxes, 14 checkboxes, 162 total clicks
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