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]
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