Orthopedic Pain

HPI:
Team member presents today with [select name="side" value="left|right|bilateral|front|left sided|right sided"] [checkbox name="where" value="wrist pain|hand pain|thumb pain|elbow pain|forearm pain|bicep pain|back pain|shoulder pain|knee pain|ankle pain|neck pain|leg pain|foot pain"].
Symptoms started [select name="time" value="today|yesterday|2-3 days ago|4-6 days ago|1 week ago|2 weeks ago|3-4 weeks ago|a month ago|more than a month ago"]. [select name="heshe" value="he|she"] first noticed symptoms when [text name="what" size="15"].
Symptoms [select name="symptoms" value="have gradually worsened|have gradually improved|have remained the same since onset|have rapidly improved|have rapidly worsened|have resolved"]. [select name="hisher" value="his|her"] pain level today is [select name="pain" value="1|2|3|4|5|6|7|8|9|10"]/10. 
[select name="heshe" value="he|she"] has tried [checkbox name="tried" value="Ice|heat|ibuprofen|tylenol|icy hot|rest|stretching|working with ergo|wearing a brace|***"] with [select name="help" value="no relief|minimal relief|moderate relief|significant relief|***"]. 
Physical Examination:
Flexion: [select name="exam" value="normal|normal with discomfort|normal with pain|diminished|significantly reduced|unable to perform"]
Extension:[select name="exam1" value="normal|normal with discomfort|normal with pain|diminished|significantly reduced|unable to perform"]
Range of Motion:[select name="exam2" value="normal|normal with discomfort|normal with pain|diminished|significantly reduced|unable to perform"]
Push/Pull Testing: [select name="exam3" value="normal|push force weakened, pull force normal|push force normal, pull force weakened|weakened|***|"]
Other:[text name="other1" size="15"].

In Office:
[checkbox name="inoffice" value="Iced the area for 10min|Oral: ___mg Ibuprofen |Oral: ___mg Tylenol|biofreeze massaged into the area for two minutes|Provided stretching handout|Provided a brace|Notified Ergo and requested an evaluation|***"].
Record of injury [select name="ROI" value="is not required.|is required and was completed.|is required and missed, will call team member back to complete.|***"]
Plan:
[checkbox name="plan" value="Ice 10-15min twice daily as needed|Take ibuprofen every 6-8 hours as needed|Take tylenol every 6-8 hours as needed|Alternate between tylenol and ibuprofen every 4 hours as needed|Perform provided stretches 3-5 times daily|Apply biofreeze to the area 2-3 times daily as needed|Wear brace while working, remove during breaks and at night|Follow up with Ergo (Ryan), I will notify him to visit you|Follow up with your primary care physician|Follow up with health services in 2-3 days if no improvement|See Provider at mainsite on _________ at ______am/pm|***"]