Musculoskeletal & Rheumatology
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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
Date of Injury:


Type of Injury:


Provocation/Palliation:
Quality/Quantity:
Region/Radiation:
Severity Now (0-10):

Severity at Worst (0-10):

Timing:



Associated Pain (0=none, 10=severe)
Location:
Radiation:
Severity now (0-10):
Severity at worst (0-10):
Duration:
Characterized as
Relieved with
Worse with
Is the pain increasing or decreasing with time?

Associated Joint Symptoms
Location:
<-- Stiffness
<-- Redness
<-- Swelling
<-- Locking or catching
<-- Giving way or unstable sensation


Pitfall evaluation:
<-- distal numbness
<-- distal weakness
<-- distal cold sensation, pallor, or cyanosis
<-- fever
<-- neck pain
<-- chest pain

Result - Copy and paste this output:

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