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