Upper Back Pain History

Neck/Upper Back 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]
[select value="no|YES"] <--  worse with cough or deep breathing

Pitfall evaluation:
[select value="no|YES"] <--  fever
[select value="no|YES"] <--  chest pain
[select value="no|YES"] <--  shortness of breath
[select value="no|YES"] <--  extremity weakness
[select value="no|YES"] <--  prior neck or back pain history with last episode 
[select value="no|YES"] <--  intervertebral disc injury
[select value="no|YES"] <--  spine surgery history
[select value="no|YES"] <--  compression fracture or osteoporosis history
[select value="no|YES"] <--  heart disease history
[select value="no|YES"] <--  aortic dissection history or risk (hypertension)
[select value="no|YES"] <--  peptic ulcer disease history
Neck/Upper Back Pain/Injury
Onset prior to evaluation
Onset while:
Injury at:

Associated Pain (0=none, 10=severe)
Location:
Radiation:
Severity now (0-10):
Severity at worst (0-10):
Duration:
Characterized as .

Relieved with
Worse with
<-- worse with cough or deep breathing

Pitfall evaluation:
<-- fever
<-- chest pain
<-- shortness of breath
<-- extremity weakness
<-- prior neck or back pain history with last episode
<-- intervertebral disc injury
<-- spine surgery history
<-- compression fracture or osteoporosis history
<-- heart disease history
<-- aortic dissection history or risk (hypertension)
<-- peptic ulcer disease history

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.08, 12 form elements, 138 boilerplate words, 11 text boxes, 1 drop downs, 12 total clicks
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