MS Eval
Date of Injury: [date name="variable_1" default="12/14/2019"] Type of Injury: [checkbox name="variable_1" value="MVA|Occupational|Trauma|Assault|Other"] Provocation/Palliation: [text] Quality/Quantity: [text] Region/Radiation: [text] Severity Now (0-10): [select name="variable_1" value="1 |2 | 3| 4| 5| 6| 7| 8| 9| 10"] Severity at Worst (0-10): [select name="variable_1" value="1 |2 | 3| 4| 5| 6| 7| 8| 9| 10"] Timing: [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] Is the pain increasing or decreasing with time? [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 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
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Sandbox Metrics: Structured Data Index 0.52, 29 form elements, 102 boilerplate words, 14 text boxes, 1 dates, 1 checkboxes, 13 drop downs, 33 total clicks
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