Low Back Pain/Injury History

Low Back Pain/Injury
Onset [text] prior to evaluation
Onset while:  [text]
Injury at: [text]

Associated Pain (0=none, 10=severe)
Location: [text]
Radiation: [text]
Severity now (0-10): [text]
Severity at worst (0-10): [text]
Duration: [text]
Characterized as [text].

Relieved with [text]
Worse with [text]
[select value="no|YES"] <-- worse with cough

Pitfall evaluation:
[select value="no|YES"] <-- fever
[select value="no|YES"] <-- hematuria
[select value="no|YES"] <-- inner thigh numbness
[select value="no|YES"] <-- foot drop
[select value="no|YES"] <-- urine retention or incontinence
[select value="no|YES"] <-- stool retention or incontinence

[select value="no|YES"] <-- prior back pain history with last episode [text]
[select value="no|YES"] <-- intervertebral disc injury
[select value="no|YES"] <-- spine surgery history

[select value="no|YES"] <-- compression fracture or osteoporosis history
[select value="no|YES"] <-- nephrolithiasis history
[select value="no|YES"] <-- peptic ulcer disease history
[select value="no|YES"] <-- aortic aneurysm history or risk (age over 60, tobacco history)
[checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"]
reference: contributed by Dr. Scott Moses, creator/author of the Family Practice Notebook [link url="http://www.fpnotebook.com" memo="website"][/conditional]