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