Upper Extremity 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]

Associated Joint Symptoms
Location: [text]
[select value="no|YES"] <-- Stiffness
[select value="no|YES"] <-- Redness
[select value="no|YES"] <-- Swelling
[select value="no|YES"] <-- Locking or catching
[select value="no|YES"] <-- Giving way or unstable sensation

Dominant hand: [text]

Pitfall evaluation:
[select value="no|YES"] <-- distal numbness
[select value="no|YES"] <-- distal weakness
[select value="no|YES"] <-- distal cold sensation, pallor, or cyanosis
[select value="no|YES"] <-- fever
[select value="no|YES"] <-- neck pain
[select value="no|YES"] <-- chest pain

Pertinent PMH:
[select value="no|YES"] <-- arthritis history
[select value="no|YES"] <-- prior extremity pain/injury history
[select value="no|YES"] <-- cervical disc history
[select value="no|YES"] <-- heart disease 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="//www.fpnotebook.com" memo="(link)"][/conditional]