Assessment & Plan Elements
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Consultation Date: [date name="variable_b1" default=""]
Patient’s name:[select name="gender" value="Mr.|Mrs"][text name="variable_b2" default=""]
Date birth:[text name="variable_b3" default=""]
Dear Dr. [text name="variable_1" default=""]
Thank you for referring this [text name="variable_2" default=""] years old [select name="variable_3" value="right|left"] handed [select name="variable_4" value="gentleman|lady"] to pain care Clinic [select name="variable_b4" value="St. Catharines|orangeville|mississauga|hamilton|Oakville|Windsor|vaughan|woodbridge|halifax|niagara falls"] site for chronic pain assessment and management.

HISTORY OF PRESENTING COMPLAINT/S
[conditional field="gender" condition="(gender).is('Mrs')"] her [/conditional][conditional field="gender" condition="(gender).is('Mr.')"] his [/conditional]main complaint is [select name="Q1" value="|headache|neck pain|upper back pain|low back pain|shoulder pain|hip pain|knee pain|ankle pain|foot pain|groin pain"][conditional field="Q1" condition="(Q1).is('headache')"] for the past [text name="variable_7" default=""]. the pain is [select name="variable_8" value="bilateral|unilateral over left side|unilateral over right side|over whole head|in front of head|back of head"] , [select name="variable_b5" value="constant|off and on|intermittent"] pain with characters of [checkbox name="variable_9" value="throbbing|band-like|tightening|dull|achy|sharp|shooting|burning|tingling|cramping|colldness|numbness"] [text name="variable_b6" default="] feeling for [select name="variable_b53" value="1|1/2|2|3|4|5|6|7|8|9|a|an"] [select name="variable_b54" value="day|days|second|seconds|minute|minutes|hour|hours|week|weeks|month|months"] [select name="variable_b55" value="|and starts from back of head toward front|and starts from front side of head and goes to back of head|and starts from base of neck|"] [text name="variable_b56" default=""]. [select name="variable_b50" value="|there is no nausea, vomiting photophobia, phonophobia or vision changes|pain accompanied with nausea and vomiting|there is nausea feeling with pain|there is photophobia|there is blury vision accompanied with pain|"] [text name="variable_b51" default=""].
On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q1" condition="(Q1).is('neck pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q1" condition="(Q1).is('upper back pain')"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q1” condition="(Q1).is('low back pain')"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q1" condition="(Q1).is('shoulder pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q1" condition="(Q1).is('knee pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q1" condition="(Q1).is('hip pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q1" condition="(Q1).is('ankle pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""][/conditional][conditional field="Q1" condition="(Q1).is('foot pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""][/conditional][conditional field="Q1" condition="(Q1).is('groin pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional]
[select name="variable_b57" value="|He also has complaint of|She also has complaint of "] [text name="variable_b59" default=""] [select name="Q2" value="|headache|neck pain|upper back pain|low back pain|shoulder pain|hip pain|knee pain|ankle pain|foot pain|groin pain"][conditional field="Q2" condition="(Q2).is('headache')"] for the past [text name="variable_7" default=""]. the pain is [select name="variable_8" value="bilateral|unilateral over left side|unilateral over right side|over whole head|in front of head|back of head"] , [select name="variable_b5" value="constant|off and on|intermittent"] pain with characters of [checkbox name="variable_9" value="throbbing|band-like|tightening|dull|achy|sharp|shooting|burning|tingling|cramping|colldness|numbness"] [text name="variable_b6" default="] feeling for [select name="variable_b53" value="1|1/2|2|3|4|5|6|7|8|9|a|an"] [select name="variable_b54" value="day|days|second|seconds|minute|minutes|hour|hours|week|weeks|month|months"] [select name="variable_b55" value="|and starts from back of head toward front|and starts from front side of head and goes to back of head|and starts from base of neck|"] [text name="variable_b56" default=""]. [select name="variable_b50" value="|there is no nausea, vomiting photophobia, phonophobia or vision changes|pain accompanied with nausea and vomiting|there is nausea feeling with pain|there is photophobia|there is blury vision accompanied with pain|"] [text name="variable_b51" default=""].
On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q2" condition="(Q2).is('neck pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q2" condition="(Q2).is('upper back pain')"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q2” condition="(Q2).is('low back pain')"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q2" condition="(Q2).is('shoulder pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q2" condition="(Q2).is('knee pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q2" condition="(Q2).is('hip pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q2" condition="(Q2).is('ankle pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""][/conditional][conditional field="Q2" condition="(Q2).is('foot pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""][/conditional][conditional field="Q2" condition="(Q2).is('groin pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional]
[select name="Q3" value="|headache|neck pain|upper back pain|low back pain|shoulder pain|hip pain|knee pain|ankle pain|foot pain|groin pain"][conditional field="Q3" condition="(Q3).is('headache')"] for the past [text name="variable_7" default=""]. the pain is [select name="variable_8" value="bilateral|unilateral over left side|unilateral over right side|over whole head|in front of head|back of head"] , [select name="variable_b5" value="constant|off and on|intermittent"] pain with characters of [checkbox name="variable_9" value="throbbing|band-like|tightening|dull|achy|sharp|shooting|burning|tingling|cramping|colldness|numbness"] [text name="variable_b6" default="] feeling for [select name="variable_b53" value="1|1/2|2|3|4|5|6|7|8|9|a|an"] [select name="variable_b54" value="day|days|second|seconds|minute|minutes|hour|hours|week|weeks|month|months"] [select name="variable_b55" value="|and starts from back of head toward front|and starts from front side of head and goes to back of head|and starts from base of neck|"] [text name="variable_b56" default=""]. [select name="variable_b50" value="|there is no nausea, vomiting photophobia, phonophobia or vision changes|pain accompanied with nausea and vomiting|there is nausea feeling with pain|there is photophobia|there is blury vision accompanied with pain|"] [text name="variable_b51" default=""].
On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q3" condition="(Q3).is('neck pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q3" condition="(Q3).is('upper back pain')"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q3” condition="(Q3).is('low back pain')"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q3" condition="(Q3).is('shoulder pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q3" condition="(Q3).is('knee pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q3" condition="(Q3).is('hip pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q3" condition="(Q3).is('ankle pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""][/conditional][conditional field="Q3" condition="(Q3).is('foot pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""][/conditional][conditional field="Q3" condition="(Q3).is('groin pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional]
[select name="Q4" value="|headache|neck pain|upper back pain|low back pain|shoulder pain|hip pain|knee pain|ankle pain|foot pain|groin pain"][conditional field="Q4" condition="(Q4).is('headache')"] for the past [text name="variable_7" default=""]. the pain is [select name="variable_8" value="bilateral|unilateral over left side|unilateral over right side|over whole head|in front of head|back of head"] , [select name="variable_b5" value="constant|off and on|intermittent"] pain with characters of [checkbox name="variable_9" value="throbbing|band-like|tightening|dull|achy|sharp|shooting|burning|tingling|cramping|colldness|numbness"] [text name="variable_b6" default="] feeling for [select name="variable_b53" value="1|1/2|2|3|4|5|6|7|8|9|a|an"] [select name="variable_b54" value="day|days|second|seconds|minute|minutes|hour|hours|week|weeks|month|months"] [select name="variable_b55" value="|and starts from back of head toward front|and starts from front side of head and goes to back of head|and starts from base of neck|"] [text name="variable_b56" default=""]. [select name="variable_b50" value="|there is no nausea, vomiting photophobia, phonophobia or vision changes|pain accompanied with nausea and vomiting|there is nausea feeling with pain|there is photophobia|there is blury vision accompanied with pain|"] [text name="variable_b51" default=""].
On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q4" condition="(Q4).is('neck pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q4" condition="(Q4).is('upper back pain')"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q4” condition="(Q4).is('low back pain')"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q4" condition="(Q4).is('shoulder pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q4" condition="(Q4).is('knee pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q4" condition="(Q4).is('hip pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q4" condition="(Q4).is('ankle pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""][/conditional][conditional field="Q4" condition="(Q4).is('foot pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""][/conditional][conditional field="Q4" condition="(Q4).is('groin pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional]
[select name="Q5" value="|headache|neck pain|upper back pain|low back pain|shoulder pain|hip pain|knee pain|ankle pain|foot pain|groin pain"][conditional field="Q5" condition="(Q5).is('headache')"] for the past [text name="variable_7" default=""]. the pain is [select name="variable_8" value="bilateral|unilateral over left side|unilateral over right side|over whole head|in front of head|back of head"] , [select name="variable_b5" value="constant|off and on|intermittent"] pain with characters of [checkbox name="variable_9" value="throbbing|band-like|tightening|dull|achy|sharp|shooting|burning|tingling|cramping|colldness|numbness"] [text name="variable_b6" default="] feeling for [select name="variable_b53" value="1|1/2|2|3|4|5|6|7|8|9|a|an"] [select name="variable_b54" value="day|days|second|seconds|minute|minutes|hour|hours|week|weeks|month|months"] [select name="variable_b55" value="|and starts from back of head toward front|and starts from front side of head and goes to back of head|and starts from base of neck|"] [text name="variable_b56" default=""]. [select name="variable_b50" value="|there is no nausea, vomiting photophobia, phonophobia or vision changes|pain accompanied with nausea and vomiting|there is nausea feeling with pain|there is photophobia|there is blury vision accompanied with pain|"] [text name="variable_b51" default=""].
On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q5" condition="(Q5).is('neck pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q5" condition="(Q5).is('upper back pain')"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q5” condition="(Q5).is('low back pain')"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q5" condition="(Q5).is('shoulder pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q5" condition="(Q5).is('knee pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q5" condition="(Q5).is('hip pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q5" condition="(Q5).is('ankle pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""][/conditional][conditional field="Q5" condition="(Q5).is('foot pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""][/conditional][conditional field="Q5" condition="(Q5).is('groin pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional]
[select name="Q6" value="|headache|neck pain|upper back pain|low back pain|shoulder pain|hip pain|knee pain|ankle pain|foot pain|groin pain"][conditional field="Q6" condition="(Q6).is('headache')"] for the past [text name="variable_7" default=""]. the pain is [select name="variable_8" value="bilateral|unilateral over left side|unilateral over right side|over whole head|in front of head|back of head"] , [select name="variable_b5" value="constant|off and on|intermittent"] pain with characters of [checkbox name="variable_9" value="throbbing|band-like|tightening|dull|achy|sharp|shooting|burning|tingling|cramping|colldness|numbness"] [text name="variable_b6" default="] feeling for [select name="variable_b53" value="1|1/2|2|3|4|5|6|7|8|9|a|an"] [select name="variable_b54" value="day|days|second|seconds|minute|minutes|hour|hours|week|weeks|month|months"] [select name="variable_b55" value="|and starts from back of head toward front|and starts from front side of head and goes to back of head|and starts from base of neck|"] [text name="variable_b56" default=""]. [select name="variable_b50" value="|there is no nausea, vomiting photophobia, phonophobia or vision changes|pain accompanied with nausea and vomiting|there is nausea feeling with pain|there is photophobia|there is blury vision accompanied with pain|"] [text name="variable_b51" default=""].
On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q6" condition="(Q6).is('neck pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q6" condition="(Q6).is('upper back pain')"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q6” condition="(Q6).is('low back pain')"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q6" condition="(Q6).is('shoulder pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q6" condition="(Q6).is('knee pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q6" condition="(Q6).is('hip pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional][conditional field="Q6" condition="(Q6).is('ankle pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""][/conditional][conditional field="Q6" condition="(Q6).is('foot pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""][/conditional][conditional field="Q6" condition="(Q6).is('groin pain')"] [select name="variable_b56" value="bilaterally|over left side|over right side|bilaterally and more over left side|bilaterally and more over right side"] for the past [text name="variable_7" default=""].The pain resulted from [text name="variable_8" default=""] and has been described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] [select name="variable_b5" value="constant|off and on|intermittent"] pain with character of [checkbox name="variable_9" value="dull|achy|sharp|shooting|burning|tingling|cramping|coldness|numbness"] [text name="variable_b6" default="] feeling. On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] that radiate to [text name="variable_16" default=""], symptoms are worsened by [text name="variable_17" default=""] and relieved by [text name="variable_18" default=""] [/conditional].
Fibromyalgia Rapid Screening Tool: [select name="variable_20" value="0/6|1/6|2/6|3/6|4/6|5/6|6/6|form not filled"] , [select name="variable_21" value="is not suggestive of|is suggestive of|that can be helpful"] for diagnosis of fibromyalgia. Total BPI Interference Score is [text name="variable_15" default="/70"]
[checkbox name="variable_22" value="With respect to the patient’s complaint of back pain, the patient reports no bowel or bladder dysfunction. There is no saddle anaesthesia, weakness or radiation reported. No thoracic pain, fever, weight loss, night sweats, immunosuppression or history of carcinoma. The patient denies overt trauma, I.V. drug use, chronic steroid use or substantive night pain.|With respect to the patient’s complaint of neck pain the patient reports no paresthesia, weakness or radiation. No thoracic pain, fever, weight loss, night sweats, immunosuppression or history of carcinoma. The patient denies overt trauma, I.V drug use, chronic steroid use or substantive night pain.|The patient’s headache is not associated with nausea, vomiting, photophobia, or phonophobia. There are not reported visual changes or aura. No history of syncope, seizure or head injury. No fever/chills or signs of systemic infection. No history of hypertension. There are no indications of medication overuse headache."]

CONSULTATIONS and Other Healthcare Professionals: [textarea name="variable_23" default=""]
PAST MEDICAL HISTORY
1. Surgical:[text name="variable_25" default=""]
2. Medical:[text name="variable_26" default=""]
FUNCTONAL INQUIRY
General functional inquiry including cardiovascular, respiratory, gastrointestinal, genitourinary, haematological and endocrine systems was unremarkable at the moment. No other musculoskeletal or neurological issues were reported other than the chief complaints. [text name="variable_b58" default=""]
PREVIOUS INVESTIGATIONS
[textarea name="variable_27" default=""]
PAST PAIN MEDICATIONS
[textarea name="variable_32" default=""]
CURRENT MEDICATIONS
[textarea name="variable_449" default=""]
The patient’s current narcotic dose is [text name="variable_32" default=""] MED. This [select name="variable_33" value="exceeds|falls within"] the NOUGG.
ALLERGIES
Medications: [text name="variable_34" default="NKDA"]
Environmental:[text name="variable_35" default="Nill"]
SOCIAL HISTORY
The patient is currently [checkbox name="variable_36" value="single|married|widow|common law|divorced"] and is Presently living [text name="variable_37" default=""]. The patient has [select name="variable_38" value="no|1|2|3|4|5|6|7"] children, [select name="variable_40" value="he|she"] [select name="variable_b10" value="is Currently on Disability and has been so since|Patient is currently unemployed and has been so since|the patient is retired|was working as"] [text name="variable_41" default=""].The patient’s highest level of education completed is [text name="variable_b11" default=""]
PSYCHOLOGICAL STATUS AND RELATED MATTERS
There [select name="variable_b12" value="is no|is|"] history of suicidal ideation and the patient [select name="variable_b13" value="has had no|had|"] previous suicide attempts. The current suicide risk is [select name="variable_b14" value="low|moderate|high"]. The patient [select name="variable_b15" value="does not see|sees|under observe of"] a psychiatrist. Hamilton Depression Rating Scale (HAM-D): [text name="variable_b16" default=""], HAM-A [text name="variable_b17" default=""] consistent with [select name="variable_b18" value="low|medium|high"] for depression and [select name="variable_b19" value="low|medium|high"] for anxiety.
Smoking: [select name="C1" value="non smoker|Ex-smoker|current smoker"] [text name="C2" default=""]
Alcohol: [select name="C3" value="not a drinker|social drinker|heavy drinker"] [text name="C4" default=""]
Illicit drug: [select name="C5" value="denies using the drug|social user|on medical cannabis|current user"] [text name="C6" default=""]
Sexual function is reported [checkbox name="variable_b20" value="unimpaired|is adversely affected|both desire and physical ability are reduced by pain/medication"]. [select name="variable_b21" value="he|she"] is [select name="variable_b22" value="unconcerned|concerned"] about this issue.[text name="variable_b23" default=""] Sleep is generally [select name="variable_b24" value="refreshing|un-refreshing"]. There [select name="variable_b25" value="is no|is"] latency in sleep onset with [select name="variable_b26" value="no|frequent"] interruptions due to the pain. The patient reports [select name="variable_b27" value="no awakening|awakening every"] [text name="variable_b28" default=""]. Medication [select name="variable_b29" value="is not|is"] utilized as a sleep aid. [text name="variable_b30" default=""]
ADDICTION RISK
1. Gender
[select name="Q1" value="Male|Female"][conditional field="Q1" condition="(Q1).is('Male')"]
2. Age
16-45 Years old (1 point) [select name="Q4m" value="no=0|YES=1"]
3. Family history of substance abuse
Alcohol (3 points) [select name="Q2m1" value="no=0|YES=3"]
Illegal drugs (3 points) [select name="Q2m2" value="no=0|YES=3"]
Prescription drugs (4 points) [select name="Q2m3" value="no=0|YES=4"]
4. Personal history of substance abuse
Alcohol (3 points) [select name="Q3m1" value="no=0|YES=3"]
Illegal drugs (4 points) [select name="Q3m2" value="no=0|YES=4"]
Prescription drugs (5 points) [select name="Q3m3" value="no=0|YES=5"]
5. Psychological disease
ADHD/OCD/Schizophrenia/Bipolar (2 points) [select name="Q5m1" value="no=0|YES=2"]
Depression (1 point) [select name="Q5m2" value="no=0|YES=1"]
Score : [calc memo="Score" value="score1=(Q2m1)+(Q2m2)+(Q2m3)+(Q3m1)+(Q3m2)+(Q3m3)+(Q4m)+(Q5m1)+(Q5m2)"]
Interpretation --> [calc memo="Interpretation" value="score2=(Q2m1)+(Q2m2)+(Q2m3)+(Q3m1)+(Q3m2)+(Q3m3)+(Q4m)+(Q5m1)+(Q5m2);score2>7?'High risk':score2>3?'Moderate risk':'Low risk'"][/conditional][conditional field="Q1" condition="(Q1).is('Female')"]
2. Age
16-45 Years old (1 point) [select name="Q4f" value="no=0|YES=1"]
3. Family history of substance abuse
Alcohol (1 points) [select name="Q2f1" value="no=0|YES=1"]
Illegal drugs (2 points) [select name="Q2f2" value="no=0|YES=2"]
Prescription drugs (4 points) [select name="Q2f3" value="no=0|YES=4"]
4. Personal history of substance abuse
Alcohol (3 points) [select name="Q3f1" value="no=0|YES=3"] [select name="Q3f2" Illegal drugs (4 points) value="no=0|YES=4"]
Prescription drugs (5 points) [select name="Q3f3" value="no=0|YES=5"]
Preadolescent sexual abuse (3 points) [select name="Q3f4" value="no=0|YES=3"]
5. Psychological disease
ADHD/OCD/Schizophrenia/Bipolar (2 points) [select name="Q5f1" value="no=0|YES=2"]
Depression (1 point) [select name="Q5f2" value="no=0|YES=1"]
Score --> [calc memo="Score" value="score3=(Q2f1)+(Q2f2)+(Q2f3)+(Q3f1)+(Q3f2)+(Q3f3)+(Q3f4)+(Q4f)+(Q5f1)+(Q5f2)"]
Interpretation --> [calc memo="Interpretation" value="score4=(Q2f1)+(Q2f2)+(Q2f3)+(Q3f1)+(Q3f2)+(Q3f3)+(Q3f4)+(Q4f)+(Q5f1)+(Q5f2);score4>7?'High risk':score4>3?'Moderate risk':'Low risk'"][/conditional]
[checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"]
reference:
posted by: Jonathan Poon
[link url="//www.ncbi.nlm.nih.gov/pubmed/16336480" memo="#1"] Webster (2005) Pain Med 6(6): 432-42
[/conditional]
Urine Drug Screen:
OXY [select name="variable_b30" value="neg|pos"] TCA: [select name="variable_b31" value="neg|pos"] AMP: [select name="variable_b32" value="neg|pos"] MOP: [select name="variable_b33" value="neg|pos"] BZO: [select name="variable_b34" value="neg|pos"] MTD: [select name="variable_b35" value="neg|pos"] BAR: [select name="variable_b36" value="neg|pos"] MAMP:[select name="variable_b37" value="neg|pos"] COC: [select name="variable_b38" value="neg|pos"] THC: [select name="variable_b39" value="neg|pos"]

PHYSICAL EXAMINATION
Age: [text name="D1" default=""] BP: [text name="D2" default=""] HR: [text name="D3" default=""] Weight: [text name="D4" default=""] [select name="D5" value="|right-habded|left-handed"][select name="D6" value="female|male"]
On physical exam today, I found [conditional field="gender" condition="(gender).is('Mrs')"]her [/conditional][conditional field="gender" condition="(gender).is('Mr.')"]him [/conditional]to be [select name="variable_31" value="alert and cooperative|non cooperative|confused"], [select name="variable_32" value="well|poor"] oriented to person, place and time. [conditional field="gender" condition="(gender).is('Mrs')"] She [/conditional][conditional field="gender" condition="(gender).is('Mr.')"]He[/conditional] has [select name="variable_33" value="good|poor|needs help for"] communication skills, recent and remote memory [select name="variable_34" value="are intact|are impaired|poor"]. [select name="variable_35" value="normal|poor"] insight and judgment, affect and mood appeared [select name="variable_36" value="congruent and within normal limits|non congruent|are congruent and down"], was [select name="variable_37" value="able|not able"] to follow commands and cooperated with the examination. [conditional field="gender" condition="(gender).is('Mrs')"]her [/conditional][conditional field="gender" condition="(gender).is('Mr.')"]His[/conditional] body Type is [select name="variable_38" value="normal|slightly overweight|overweight|frail"] and appears [select name="variable_39" value="well|poor"] conditioned. I asked [conditional field="gender" condition="(gender).is('Mrs')"]her [/conditional][conditional field="gender" condition="(gender).is('Mr.')"]him [/conditional]to walk and [conditional field="gender" condition="(gender).is('Mrs')"]her [/conditional][conditional field="gender" condition="(gender).is('Mr.')"]his [/conditional]gait [select name="variable_40" value="looks normal in short distance walking|anthalgic|is shuffling gait|is wide base gait| cannot be assessed|cannot be assessed, sits on wheelchair"] with [select name="variable_611" value="upright|mildly kyphotic|kyphotic|stooped forward"] posture, [conditional field="gender" condition="(gender).is('Mrs')"] She [/conditional][conditional field="gender" condition="(gender).is('Mr.')"]He[/conditional] has a [select name="variable_8463" value="normal|slow"] get up and go.[text name="variable_3001" default=""]
My objective findings as related to [conditional field="gender" condition="(gender).is('Mrs')"] her [/conditional][conditional field="gender" condition="(gender).is('Mr.')"]his [/conditional]injuries are as follows:

[select name="U1" value="|HEAD & FACE|NECK|UPPER BACK|LOWER BACK|SHOULDER|ELBOW|WRIST|HIP|KNEE|ANKLE & FOOT"] [conditional field="U1" condition="(U1).is('HEAD & FACE')"]
Power is [select name="variable_150" value="normal bilaterally|weak bilaterally|weak right side|weak left side"] [text name="variable_power1" default="."]Sensation to light touch is [select name="variable_151" value="intact and equal bilaterally|decreased over left side|decreased over right side"][text name="variable_power2" default="."]there [select name="variable_152" value="is no|is"] hyperesthesia,hypoesthesia, allodynia. in palpation over TMJ regions, supraorbital, infraorbital, temporal, lesser and greater occipital nerve, Splenius Capitus and sternocleidomastoid muscle [select name="variable_154" value="are non tender|reveled tenderness over"] [text name="variable_155" default="."] [/conditional] [conditional field="U1" condition="(U1).is('NECK')"]
Inspection of the neck and cervical spine for signs of muscle spasm, muscle wasting and skin changes [select name="variable_747" value="was normal|revealed|"] [text name="variable_b60" default="."]palpation of neck and cervical area mainly over cervical spinous process and para-vertebral muscles [select name="variable_745" value="were normal|There is tenderness over|"] [text name="variable_748" default=""]. cervical range of motion in forward flexion, Extension, right and left Lateral bending [select name="variable_7" value="are within acceptable ranges|decreased|are limited in all directions|restricted|are normal but reports pain on|are normal"] [text name="variable_b61" default="."] strength checked with resisted internal rotation, external rotation, resisted flexion and extension [select name="variable_767" value="was within normal limits|revealed weakness over"] [text name="variable_768" default="."] Atlanto-axial compression (Spurling) test [select name="variable_760" value="was negative|was positive|caused pain|caused pain over right side|caused pain over left side"][text name="variable_power3" default="."]Light touch of face and neck [select name="variable_762" value="did not reveal|showed"] allodynia/hypoesthesia [text name="variable_b63" default="."] [/conditional]
[conditional field="U1" condition="(U1).is('SHOULDER')"]
Inspection of both exposed shoulders from front and back for asymmetry, atrophy, swelling, ecchymosis, deformity and venous distention [select name="variable_p8" value="was normal|was positive for"] [text name="variable_158" default="."]
apprehension test for shoulder stability was [select name="variable_159" value="negative bilaterally| positive right side| positive left side|positive bilaterally"].
palpation over sternoclavicular joint, clavicle, AC joint, bicipital groove, glenohumeral joint, anterior subacromial space, posterior subacromial space, rotator cuff tendons, spinous process and paraspinous muscles [select name="variable_161" value="did not elicit tenderness| caused tenderness over"] [text name="variable_691" default="."]
Range of motion performed actively and passively in forward flexion, extension, abduction, external rotation, internal rotation and horizontal abduction [select name="variable_CC1" value="are within acceptable range|limited over|limited in all directions"] [text name="variable_b65" default="."]
strength checked with resisted internal rotation, external rotation, resisted abduction and adduction are [select name="variable_170" value="within normal limits| revealed weakness over"] [text name="variable_171" default="."]
exam for biceps tendons [select name="variable_172" value="was negative bilaterally| was positive over right shoulder| was positive over left shoulder|was positive bilaterally"].
impingement test [select name="variable_173" value="was negative| was positive over right shoulder| was positive over left shoulder|was positive both shoulders"].
Labrum grind test was [select name="variable_174" value="negative| positive"] [text name="variable_b66" default="."]
[/conditional][conditional field="U1" condition="(U1).is('ELBOW')"]
Inspection for gross deformity, edema/swelling, effusion, echymosis and skin changes [select name="variable_CC2" value="did not reveal abnormality|was normal|has"] [text name="variable_CC3" default="."]
Palpation of olecranon, antecubital fossa, medial epicondyle and lateral epicondyle [select name="variable_CC5" value="had no tenderness|were normal|revealed tenderness over"] [text name="variable_CC6" default="."]
Range of motion in flexion and extension [select name="variable_CC7" value="were full and not painful|were full but painful|limited|limited and painful"] [text name="variable_CC8" default="."] [/conditional][conditional field="U1" condition="(U1).is('WRIST')"]
Inspection for gross deformity, skin changes, deviation and swelling [select name="variable_CC9" value="are normal|has|"] [text name="variable_CC10" default="."]
Palpation of dorsal aspect, volar aspect, medial aspect and lateral aspect of both wrists [select name="variable_CC12" value="looks normal|has|"] [text name="variable_CC13" default="."]
Range of motion in flexion, extension, abduction and adduction [select name="variable_CC14" value="are within normal limits and not painful|within normal limits and painful|limited|limited and not painful|limited and painful "] [text name="variable_CC15" default="."]
-Tinel's test [select value="negative|positive"]
-Phalen's test [select value="negative|positive"]
-Reverse phalen's test [select value="negative|positive"]
-Finklestein's test [select value="negative|positive"]
[text name="variable_CC17" default="."] [/conditional][conditional field="U1” condition="(U1).is('UPPER BACK')"]
Inspection of upper back for gross deformity, left and right paraspinal muscle spasm, spinal curvature, step-off deformity and scapular wing [select name="variable_CC19" value="was normal|has abnormality over|"] [text name="variable_CC20" default="."]
[select name="variable_CC21" value="no|there is antalgic|there is shuffling|"] gait abnormality [text name="variable_CC22" default="."]
in palpation of right first rib, left first rib, right and left paraspinal muscles, midline spinous processes, right and left trapezius [select name="variable_CC23" value="were normal|had no tenderness|had tenderness over|had tender points over|"] [text name="variable_CC24" default="."]
Range of motion of thoracolumbar in flexion, extension, right and left side-bend, right and left rotation [select name="variable_CC25" value="are normal|normal and painful|limited on|"] [text name="variable_CC26" default="."]
Spurling's test [select value="negative b/l|positive right side|positive left side|positive bilaterally"].
axial compression test [select name="variable_CC28" value="negative b/l|positive right side|positive left side|positive bilaterally"][/conditional]
[conditional field="U1" condition="(U1).is('LOWER BACK')"]Inspection of entire back for redness, asymmetry, deformity, scoliosis, hair growth and step off deformity [select name="variable_p9" value="did not reveal abnormalities| |showed"] [text name="variable_p10" default="."]
palpation for areas of tenderness over Spinous processus, paraspinous muscles and paravertebral muscles [select name="variable_p12" value="did not cause tenderness|there is tenderness over|there is tenderness over sacroiliac region|there is tenderness over paraspinal muscles|there is tenderness over spinous process"] [text name="variable_17" default="."]
Range of motion performed in forward flexion, extension, lateral bending and twisting [select name="variable_CC29" value="were within acceptable ranges|normal but patient reports pain over|limited in|limited in all directions|limited and painful|reduced|reduced left side|reduced right side"] [text name="variable_p15" default="."]
strength testing with heel walking, toe walking and resisted great toe dorsiflexion [select name="variable_8" value=" did not show any weakness| showed weakness over right side| showed weakness over left side|showed weakness bilaterally|cannot be assessed|"] [text name="variable_p13" default="."]
neurologic exam of deep tendon reflexes over knee and ankle [select name="variable_9" value="within normal limits|2+ and symmetric|1+ and symmetric|weak bilaterally|weak right side|weak left side|"] [text name="variable_CC30" default="."]
Straight-leg raise for sciatic nerve is [select name="variable_p14" value="negative|Positive"] [select name="variable_11" value="bilaterally|right side|left side"] [text name="variable_674" default=""].
Sacroiliac test [select name="variable_15" value="did not elicited|elicit"] SI joint pain [select name="variable_p16" value="bilaterally|over left side|over right side"], Piriformis test was [select name="variable_CC50" value="negative bilaterally|positive bilaterally|positive over right side|positive over left side"] [/conditional] [conditional field="U1" condition="(U1).is('HIP')"]
Inspection of hip from front and back had [select name="variable_900" value="normal|anthalgic|wide base|normal with slow get up and go"] gait and [select name="variable_901" value="had no asymmetry or atrophy|some asymetry noted over|atrophy noted over|"] [text name="variable_902" default="."] Palpation of anterior hip joint, anterior superior iliac spine, anterior inferior iliac spine, greater trochanters, iliotibial bands, gluteus muscle area, ischial bursa and trochanteric bursa [select name="variable_904" value="did not illicit tenderness|caused tenderness over|were not tender but patient reported pain on deep palpation of|"] [text name="variable_905" default="."]
Range of motion performed on internal rotation, external rotation, flexion, extension, abduction and adduction
[select name="variable_CC40" value="are normal|are within normal limits|limited and painful over|limited and not painful over|"] [text name="variable_914" default="."] strengths examination [select name="variable_912" value="within normal limits bilaterally|revealed weakness bilaterally|revealed weakness left side|revealed weakness right side"]. [text name="variable_915" default="."] Light touch [select name="variable_913" value="did not|did"] elicit hyperesthesia or allodynia. Sensation over lateral thigh and medial thigh [select name="variable_917" value="were normal|were absent|slightly decreased"] [text name="variable_918" default="."] trendelenburg test [select name="variable_919" value="did not|did"] cause pelvic tilt, weakness or pain. [text name="variable_920" default="."] Logroll test [select name="variable_p18" value="is negative.|is positive right side.|is positive left side.|is positive bilaterally."] [text name="variable_b69" default=""] [/conditional][conditional field="U1" condition="(U1).is('KNEE')"]
Inspection of both knee for gross deformity, gross effusion, echymosis and laterally displaced patella
[select name="variable_CC51" value="was negative bilaterraly|had|"] [text name="variable_CC52" default="."] there is [select name="variable_CC54" value="no|antalgic|shuffling|wide base|varus thrust|flexed knee gait|"] gait abnormality[text name="variable_CC55" default="."]
in palpation of patellar tendon, medial joint line, lateral joint line, pes anserine, knee bursa, quad tendon, IT band, LCL ligament, MCL ligament, popliteal fossa [select name="variable_CC57" value="no abnormality noted|no tenderness noted|has tenderness over|"] [text name="variable_CC58" default="."]
range of motion in flexion, extension, internal and external rotation [select name="variable_CC60" value="is normal bilaterally|limited over|is limited and painful over|is limited and not painful|is not limited but painful|"] [text name="variable_CC61" default="."]
patellar apprehenson test [select value="negative|positive"]
varus test [select value="negative|positive"]
valgus test [select value="negative|positive"]
lachman's test [select value="negative|positive"]
anterior drawer test [select value="negative|positive"]
posterior drawer test [select value="negative|POSITIVE"]
McMurray's test [select value="negative|positive"] [text name="variable_CC63" default="."][/conditional][conditional field="U1" condition="(U1).is('ANKLE & FOOT')"]
Inspection of both ankles for gross deformity, effusion, swelling, ecchymosis, bruises, abnormal hair loss and redness [select name="cx1" value="did not reveal any abnormality|revealed|showed|"] [select name="cx3" value="bilaterally|over left side|over right side|"] [text name="cx2" default="."]
Feet inspection has [checkbox value="normal height of plantar arches with weight bearing|high arches with weight bearing|reduced plantar arch heights with weight bearing|complete collapse of plantar arches with weight bearing|right hallux valgus|left hallux valgus|right hallux varus|left hallux varus"] [text name="cx4" default="."]
[select value="no gait abnormalities noted|Gait assessment:"] [checkbox value="antalgic but able to bear weight|unable to weight bear on right ankle|unable to weight bear over left ankle|unable to weight bear over both ankles|unable to weight bear over left foot|unable to weight bear over right foot|unable to weight bear over both feet"] [text name="cx5" default="."]
in palpation of distal fibula, anterior talofibular ligament (ATFL), posterior talofibular ligament (PTFL), calcaneal fibular ligament (CFL), distal tibia/lateral malleolus, medial malleolus, deltoid ligament complex, base of 5th metatarsal, dorsal aspect of navicular bone, proximal fibula, retro-calcaneal bursa, calcaneal bursa and medial malleus bursa [select name="cx6" value="did not cause tenderness|caused tenderness over|severe tenderness over"] [text name="cx7" default="."]
Range of motion of ankles flexion, extension, ankle inversion and ankle everson [select value="not limited & not painful|limited and painful bilaterally|reduced and painful over left side|reduced and painful over left side"] [text name="cx8" default="."] range of motion in feet on hallux flexion, hallux extension, flexion of lesser toes, extension of lesser toes, foot inversion and version"] [select name="cx20" value="are within normal limits|reduced over|restricted over"] [text name="cx21" default="."]
Talar tilt test [select name="cx9" value="negative bilaterally|positive left side|positive right side"]
Anterior drawer test [select name="cx10" value="negative bilaterally|positive left side|positive right side"]
Squeeze test [select name="cx11" value="negative bilaterally|positive left side|positive right side"]
Ankle External Rotation Test (Syndesmotic Stress Test) [select name="cx12" value="negative bilaterally|positive left side|positive right side"]
Thompson test [select value="negative|positive"] [text name="variable_CC70" default="sample text"] [/conditional] [select name="UU2" value="|HEAD & FACE|NECK|UPPER BACK|LOWER BACK|SHOULDER|ELBOW|WRIST|HIP|KNEE|ANKLE & FOOT"] [conditional field="UU2" condition="(UU2).is('HEAD & FACE')"]
Power is [select name="variable_150" value="normal bilaterally|weak bilaterally|weak right side|weak left side"] [text name="variable_power1" default="."]Sensation to light touch is [select name="variable_151" value="intact and equal bilaterally|decreased over left side|decreased over right side"][text name="variable_power2" default="."]there [select name="variable_152" value="is no|is"] hyperesthesia,hypoesthesia, allodynia. in palpation over TMJ regions, supraorbital, infraorbital, temporal, lesser and greater occipital nerve, Splenius Capitis and sternocleidomastoid muscle [select name="variable_154" value="are non-tender|reveled tenderness over"] [text name="variable_155" default="."] [/conditional] [conditional field="UU2" condition="(UU2).is('NECK')"]
Inspection of the neck and cervical spine for signs of muscle spasm, muscle wasting and skin changes [select name="variable_747" value="was normal|revealed|"] [text name="variable_b60" default="."]palpation of neck and cervical area mainly over cervical spinous process and para-vertebral muscles [select name="variable_745" value="were normal|There is tenderness over|"] [text name="variable_748" default=""]. cervical range of motion in forward flexion, Extension, right and left Lateral bending [select name="variable_7" value="are within acceptable ranges|decreased|are limited in all directions|restricted|are normal but reports pain on|are normal"] [text name="variable_b61" default="."] strength checked with resisted internal rotation, external rotation, resisted flexion and extension [select name="variable_767" value="was within normal limits|revealed weakness over"] [text name="variable_768" default="."] Atlanto-axial compression (Spurling) test [select name="variable_760" value="was negative|was positive|caused pain|caused pain over right side|caused pain over left side"][text name="variable_power3" default="."]Light touch of face and neck [select name="variable_762" value="did not reveal|showed"] allodynia/hypoesthesia [text name="variable_b63" default="."] [/conditional]
[conditional field="UU2" condition="(UU2).is('SHOULDER')"]
Inspection of both exposed shoulders from front and back for asymmetry, atrophy, swelling, ecchymosis, deformity and venous distention [select name="variable_p8" value="was normal|was positive for"] [text name="variable_158" default="."]
apprehension test for shoulder stability was [select name="variable_159" value="negative bilaterally| positive right side| positive left side|positive bilaterally"].
palpation over sternoclavicular joint, clavicle, AC joint, bicipital groove, glenohumeral joint, anterior subacromial space, posterior subacromial space, rotator cuff tendons, spinous process and paraspinous muscles [select name="variable_161" value="did not elicit tenderness| caused tenderness over"] [text name="variable_691" default="."]
Range of motion performed actively and passively in forward flexion, extension, abduction, external rotation, internal rotation and horizontal abduction [select name="variable_CC1" value="are within acceptable range|limited over|limited in all directions"] [text name="variable_b65" default="."]
strength checked with resisted internal rotation, external rotation, resisted abduction and adduction are [select name="variable_170" value="within normal limits| revealed weakness over"] [text name="variable_171" default="."]
exam for biceps tendons [select name="variable_172" value="was negative bilaterally| was positive over right shoulder| was positive over left shoulder|was positive bilaterally"].
impingement test [select name="variable_173" value="was negative| was positive over right shoulder| was positive over left shoulder|was positive both shoulders"].
Labrum grind test was [select name="variable_174" value="negative| positive"] [text name="variable_b66" default="."]
[/conditional][conditional field="UU2" condition="(UU2).is('ELBOW')"]
Inspection for gross deformity, edema/swelling, effusion, echymosis and skin changes [select name="variable_CC2" value="did not reveal abnormality|was normal|has"] [text name="variable_CC3" default="."]
Palpation of olecranon, antecubital fossa, medial epicondyle and lateral epicondyle [select name="variable_CC5" value="had no tenderness|were normal|revealed tenderness over"] [text name="variable_CC6" default="."]
Range of motion in flexion and extension [select name="variable_CC7" value="were full and not painful|were full but painful|limited|limited and painful"] [text name="variable_CC8" default="."] [/conditional][conditional field="UU2" condition="(UU2).is('WRIST')"]
Inspection for gross deformity, skin changes, deviation and swelling [select name="variable_CC9" value="are normal|has|"] [text name="variable_CC10" default="."]
Palpation of dorsal aspect, volar aspect, medial aspect and lateral aspect of both wrists [select name="variable_CC12" value="looks normal|has|"] [text name="variable_CC13" default="."]
Range of motion in flexion, extension, abduction and adduction [select name="variable_CC14" value="are within normal limits and not painful|within normal limits and painful|limited|limited and not painful|limited and painful "] [text name="variable_CC15" default="."]
-Tinel's test [select value="negative|positive"]
-Phalen's test [select value="negative|positive"]
-Reverse phalen's test [select value="negative|positive"]
-Finklestein's test [select value="negative|positive"]
[text name="variable_CC17" default="."] [/conditional][conditional field="UU2” condition="(UU2).is('UPPER BACK')"]
Inspection of upper back for gross deformity, left and right paraspinal muscle spasm, spinal curvature, step-off deformity and scapular wing [select name="variable_CC19" value="was normal|has abnormality over|"] [text name="variable_CC20" default="."]
[select name="variable_CC21" value="no|there is antalgic|there is shuffling|"] gait abnormality [text name="variable_CC22" default="."]
in palpation of right first rib, left first rib, right and left paraspinal muscles, midline spinous processes, right and left trapezius [select name="variable_CC23" value="were normal|had no tenderness|had tenderness over|had tender points over|"] [text name="variable_CC24" default="."]
Range of motion of thoracolumbar in flexion, extension, right and left side-bend, right and left rotation [select name="variable_CC25" value="are normal|normal and painful|limited on|"] [text name="variable_CC26" default="."]
Spurling's test [select value="negative b/l|positive right side|positive left side|positive bilaterally"].
axial compression test [select name="variable_CC28" value="negative b/l|positive right side|positive left side|positive bilaterally"][/conditional]
[conditional field="UU2" condition="(UU2).is('LOWER BACK')"]Inspection of entire back for redness, asymmetry, deformity, scoliosis, hair growth and step off deformity [select name="variable_p9" value="did not reveal abnormalities| |showed"] [text name="variable_p10" default="."]
palpation for areas of tenderness over Spinous processus, paraspinous muscles and paravertebral muscles [select name="variable_p12" value="did not cause tenderness|there is tenderness over|there is tenderness over sacroiliac region|there is tenderness over paraspinal muscles|there is tenderness over spinous process"] [text name="variable_17" default="."]
Range of motion performed in forward flexion, extension, lateral bending and twisting [select name="variable_CC29" value="were within acceptable ranges|normal but patient reports pain over|limited in|limited in all directions|limited and painful|reduced|reduced left side|reduced right side"] [text name="variable_p15" default="."]
strength testing with heel walking, toe walking and resisted great toe dorsiflexion [select name="variable_8" value=" did not show any weakness| showed weakness over right side| showed weakness over left side|showed weakness bilaterally|cannot be assessed|"] [text name="variable_p13" default="."]
neurologic exam of deep tendon reflexes over knee and ankle [select name="variable_9" value="within normal limits|2+ and symmetric|1+ and symmetric|weak bilaterally|weak right side|weak left side|"] [text name="variable_CC30" default="."]
Straight-leg raise for sciatic nerve is [select name="variable_p14" value="negative|Positive"] [select name="variable_11" value="bilaterally|right side|left side"] [text name="variable_674" default=""].
Sacroiliac test [select name="variable_15" value="did not elicited|elicit"] SI joint pain [select name="variable_p16" value="bilaterally|over left side|over right side"], Piriformis test was [select name="variable_CC50" value="negative bilaterally|positive bilaterally|positive over right side|positive over left side"] [/conditional] [conditional field="UU2" condition="(UU2).is('HIP')"]
Inspection of hip from front and back had [select name="variable_900" value="normal|anthalgic|wide base|normal with slow get up and go"] gait and [select name="variable_901" value="had no asymmetry or atrophy|some asymetry noted over|atrophy noted over|"] [text name="variable_902" default="."] Palpation of anterior hip joint, anterior superior iliac spine, anterior inferior iliac spine, greater trochanters, iliotibial bands, gluteus muscle area, ischial bursa and trochanteric bursa [select name="variable_904" value="did not illicit tenderness|caused tenderness over|were not tender but patient reported pain on deep palpation of|"] [text name="variable_905" default="."]
Range of motion performed on internal rotation, external rotation, flexion, extension, abduction and adduction
[select name="variable_CC40" value="are normal|are within normal limits|limited and painful over|limited and not painful over|"] [text name="variable_914" default="."] strengths examination [select name="variable_912" value="within normal limits bilaterally|revealed weakness bilaterally|revealed weakness left side|revealed weakness right side"]. [text name="variable_915" default="."] Light touch [select name="variable_913" value="did not|did"] elicit hyperesthesia or allodynia. Sensation over lateral thigh and medial thigh [select name="variable_917" value="were normal|were absent|slightly decreased"] [text name="variable_918" default="."] trendelenburg test [select name="variable_919" value="did not|did"] cause pelvic tilt, weakness or pain. [text name="variable_920" default="."] Logroll test [select name="variable_p18" value="is negative.|is positive right side.|is positive left side.|is positive bilaterally."] [text name="variable_b69" default=""] [/conditional][conditional field="UU2" condition="(UU2).is('KNEE')"]
Inspection of both knee for gross deformity, gross effusion, echymosis and laterally displaced patella
[select name="variable_CC51" value="was negative bilaterraly|had|"] [text name="variable_CC52" default="."] there is [select name="variable_CC54" value="no|antalgic|shuffling|wide base|varus thrust|flexed knee gait|"] gait abnormality[text name="variable_CC55" default="."]
in palpation of patellar tendon, medial joint line, lateral joint line, pes anserine, knee bursa, quad tendon, IT band, LCL ligament, MCL ligament, popliteal fossa [select name="variable_CC57" value="no abnormality noted|no tenderness noted|has tenderness over|"] [text name="variable_CC58" default="."]
range of motion in flexion, extension, internal and external rotation [select name="variable_CC60" value="is normal bilaterally|limited over|is limited and painful over|is limited and not painful|is not limited but painful|"] [text name="variable_CC61" default="."]
patellar apprehenson test [select value="negative|positive"]
varus test [select value="negative|positive"]
valgus test [select value="negative|positive"]
lachman's test [select value="negative|positive"]
anterior drawer test [select value="negative|positive"]
posterior drawer test [select value="negative|POSITIVE"]
McMurray's test [select value="negative|positive"] [text name="variable_CC63" default="."][/conditional][conditional field="UU2" condition="(UU2).is('ANKLE & FOOT')"]
Inspection of both ankles for gross deformity, effusion, swelling, ecchymosis, bruises, abnormal hair loss and redness [select name="cx1" value="did not reveal any abnormality|revealed|showed|"] [select name="cx3" value="bilaterally|over left side|over right side|"] [text name="cx2" default="."]
Feet inspection has [checkbox value="normal height of plantar arches with weight bearing|high arches with weight bearing|reduced plantar arch heights with weight bearing|complete collapse of plantar arches with weight bearing|right hallux valgus|left hallux valgus|right hallux varus|left hallux varus"] [text name="cx4" default="."]
[select value="no gait abnormalities noted|Gait assessment:"] [checkbox value="antalgic but able to bear weight|unable to weight bear on right ankle|unable to weight bear over left ankle|unable to weight bear over both ankles|unable to weight bear over left foot|unable to weight bear over right foot|unable to weight bear over both feet"] [text name="cx5" default="."]
in palpation of distal fibula, anterior talofibular ligament (ATFL), posterior talofibular ligament (PTFL), calcaneal fibular ligament (CFL), distal tibia/lateral malleolus, medial malleolus, deltoid ligament complex, base of 5th metatarsal, dorsal aspect of navicular bone, proximal fibula, retro-calcaneal bursa, calcaneal bursa and medial malleus bursa [select name="cx6" value="did not cause tenderness|caused tenderness over|severe tenderness over"] [text name="cx7" default="."]
Range of motion of ankles flexion, extension, ankle inversion and ankle everson [select value="not limited & not painful|limited and painful bilaterally|reduced and painful over left side|reduced and painful over left side"] [text name="cx8" default="."] range of motion in feet on hallux flexion, hallux extension, flexion of lesser toes, extension of lesser toes, foot inversion and version"] [select name="cx20" value="are within normal limits|reduced over|restricted over"] [text name="cx21" default="."]
Talar tilt test [select name="cx9" value="negative bilaterally|positive left side|positive right side"]
Anterior drawer test [select name="cx10" value="negative bilaterally|positive left side|positive right side"]
Squeeze test [select name="cx11" value="negative bilaterally|positive left side|positive right side"]
Ankle External Rotation Test (Syndesmotic Stress Test) [select name="cx12" value="negative bilaterally|positive left side|positive right side"]
Thompson test [select value="negative|positive"] [text name="variable_CC70" default="sample text"] [/conditional] [select name="UU3" value="|HEAD & FACE|NECK|UPPER BACK|LOWER BACK|SHOULDER|ELBOW|WRIST|HIP|KNEE|ANKLE & FOOT"] [conditional field="UU3" condition="(UU3).is('HEAD & FACE')"]
Power is [select name="variable_150" value="normal bilaterally|weak bilaterally|weak right side|weak left side"] [text name="variable_power1" default="."]Sensation to light touch is [select name="variable_151" value="intact and equal bilaterally|decreased over left side|decreased over right side"][text name="variable_power2" default="."]there [select name="variable_152" value="is no|is"] hyperesthesia,hypoesthesia, allodynia. in palpation over TMJ regions, supraorbital, infraorbital, temporal, lesser and greater occipital nerve, Splenius Capitus and sternocleidomastoid muscle [select name="variable_154" value="are non-tender|reveled tenderness over"] [text name="variable_155" default="."] [/conditional] [conditional field="UU3" condition="(UU3).is('NECK')"]
Inspection of the neck and cervical spine for signs of muscle spasm, muscle wasting and skin changes [select name="variable_747" value="was normal|revealed|"] [text name="variable_b60" default="."]palpation of neck and cervical area mainly over cervical spinous process and para-vertebral muscles [select name="variable_745" value="were normal|There is tenderness over|"] [text name="variable_748" default=""]. cervical range of motion in forward flexion, Extension, right and left Lateral bending [select name="variable_7" value="are within acceptable ranges|decreased|are limited in all directions|restricted|are normal but reports pain on|are normal"] [text name="variable_b61" default="."] strength checked with resisted internal rotation, external rotation, resisted flexion and extension [select name="variable_767" value="was within normal limits|revealed weakness over"] [text name="variable_768" default="."] Atlanto-axial compression (Spurling) test [select name="variable_760" value="was negative|was positive|caused pain|caused pain over right side|caused pain over left side"][text name="variable_power3" default="."]Light touch of face and neck [select name="variable_762" value="did not reveal|showed"] allodynia/hypoesthesia [text name="variable_b63" default="."] [/conditional]
[conditional field="UU3" condition="(UU3).is('SHOULDER')"]
Inspection of both exposed shoulders from front and back for asymmetry, atrophy, swelling, ecchymosis, deformity and venous distention [select name="variable_p8" value="was normal|was positive for"] [text name="variable_158" default="."]
apprehension test for shoulder stability was [select name="variable_159" value="negative bilaterally| positive right side| positive left side|positive bilaterally"].
palpation over sternoclavicular joint, clavicle, AC joint, bicipital groove, glenohumeral joint, anterior subacromial space, posterior subacromial space, rotator cuff tendons, spinous process and paraspinous muscles [select name="variable_161" value="did not elicit tenderness| caused tenderness over"] [text name="variable_691" default="."]
Range of motion performed actively and passively in forward flexion, extension, abduction, external rotation, internal rotation and horizontal abduction [select name="variable_CC1" value="are within acceptable range|limited over|limited in all directions"] [text name="variable_b65" default="."]
strength checked with resisted internal rotation, external rotation, resisted abduction and adduction are [select name="variable_170" value="within normal limits| revealed weakness over"] [text name="variable_171" default="."]
exam for biceps tendons [select name="variable_172" value="was negative bilaterally| was positive over right shoulder| was positive over left shoulder|was positive bilaterally"].
impingement test [select name="variable_173" value="was negative| was positive over right shoulder| was positive over left shoulder|was positive both shoulders"].
Labrum grind test was [select name="variable_174" value="negative| positive"] [text name="variable_b66" default="."]
[/conditional][conditional field="UU3" condition="(UU3).is('ELBOW')"]
Inspection for gross deformity, edema/swelling, effusion, echymosis and skin changes [select name="variable_CC2" value="did not reveal abnormality|was normal|has"] [text name="variable_CC3" default="."]
Palpation of olecranon, antecubital fossa, medial epicondyle and lateral epicondyle [select name="variable_CC5" value="had no tenderness|were normal|revealed tenderness over"] [text name="variable_CC6" default="."]
Range of motion in flexion and extension [select name="variable_CC7" value="were full and not painful|were full but painful|limited|limited and painful"] [text name="variable_CC8" default="."] [/conditional][conditional field="UU3" condition="(UU3).is('WRIST')"]
Inspection for gross deformity, skin changes, deviation and swelling [select name="variable_CC9" value="are normal|has|"] [text name="variable_CC10" default="."]
Palpation of dorsal aspect, volar aspect, medial aspect and lateral aspect of both wrists [select name="variable_CC12" value="looks normal|has|"] [text name="variable_CC13" default="."]
Range of motion in flexion, extension, abduction and adduction [select name="variable_CC14" value="are within normal limits and not painful|within normal limits and painful|limited|limited and not painful|limited and painful "] [text name="variable_CC15" default="."]
-Tinel's test [select value="negative|positive"]
-Phalen's test [select value="negative|positive"]
-Reverse phalen's test [select value="negative|positive"]
-Finklestein's test [select value="negative|positive"]
[text name="variable_CC17" default="."] [/conditional][conditional field="UU3” condition="(UU3).is('UPPER BACK')"]
Inspection of upper back for gross deformity, left and right paraspinal muscle spasm, spinal curvature, step-off deformity and scapular wing [select name="variable_CC19" value="was normal|has abnormality over|"] [text name="variable_CC20" default="."]
[select name="variable_CC21" value="no|there is antalgic|there is shuffling|"] gait abnormality [text name="variable_CC22" default="."]
in palpation of right first rib, left first rib, right and left paraspinal muscles, midline spinous processes, right and left trapezius [select name="variable_CC23" value="were normal|had no tenderness|had tenderness over|had tender points over|"] [text name="variable_CC24" default="."]
Range of motion of thoracolumbar in flexion, extension, right and left side-bend, right and left rotation [select name="variable_CC25" value="are normal|normal and painful|limited on|"] [text name="variable_CC26" default="."]
Spurling's test [select value="negative b/l|positive right side|positive left side|positive bilaterally"].
axial compression test [select name="variable_CC28" value="negative b/l|positive right side|positive left side|positive bilaterally"][/conditional]
[conditional field="UU3" condition="(UU3).is('LOWER BACK')"]Inspection of entire back for redness, asymmetry, deformity, scoliosis, hair growth and step off deformity [select name="variable_p9" value="did not reveal abnormalities| |showed"] [text name="variable_p10" default="."]
palpation for areas of tenderness over Spinous processus, paraspinous muscles and paravertebral muscles [select name="variable_p12" value="did not cause tenderness|there is tenderness over|there is tenderness over sacroiliac region|there is tenderness over paraspinal muscles|there is tenderness over spinous process"] [text name="variable_17" default="."]
Range of motion performed in forward flexion, extension, lateral bending and twisting [select name="variable_CC29" value="were within acceptable ranges|normal but patient reports pain over|limited in|limited in all directions|limited and painful|reduced|reduced left side|reduced right side"] [text name="variable_p15" default="."]
strength testing with heel walking, toe walking and resisted great toe dorsiflexion [select name="variable_8" value=" did not show any weakness| showed weakness over right side| showed weakness over left side|showed weakness bilaterally|cannot be assessed|"] [text name="variable_p13" default="."]
neurologic exam of deep tendon reflexes over knee and ankle [select name="variable_9" value="within normal limits|2+ and symmetric|1+ and symmetric|weak bilaterally|weak right side|weak left side|"] [text name="variable_CC30" default="."]
Straight-leg raise for sciatic nerve is [select name="variable_p14" value="negative|Positive"] [select name="variable_11" value="bilaterally|right side|left side"] [text name="variable_674" default=""].
Sacroiliac test [select name="variable_15" value="did not elicited|elicit"] SI joint pain [select name="variable_p16" value="bilaterally|over left side|over right side"], Piriformis test was [select name="variable_CC50" value="negative bilaterally|positive bilaterally|positive over right side|positive over left side"] [/conditional] [conditional field="UU3" condition="(UU3).is('HIP')"]
Inspection of hip from front and back had [select name="variable_900" value="normal|anthalgic|wide base|normal with slow get up and go"] gait and [select name="variable_901" value="had no asymmetry or atrophy|some asymetry noted over|atrophy noted over|"] [text name="variable_902" default="."] Palpation of anterior hip joint, anterior superior iliac spine, anterior inferior iliac spine, greater trochanters, iliotibial bands, gluteus muscle area, ischial bursa and trochanteric bursa [select name="variable_904" value="did not illicit tenderness|caused tenderness over|were not tender but patient reported pain on deep palpation of|"] [text name="variable_905" default="."]
Range of motion performed on internal rotation, external rotation, flexion, extension, abduction and adduction
[select name="variable_CC40" value="are normal|are within normal limits|limited and painful over|limited and not painful over|"] [text name="variable_914" default="."] strengths examination [select name="variable_912" value="within normal limits bilaterally|revealed weakness bilaterally|revealed weakness left side|revealed weakness right side"]. [text name="variable_915" default="."] Light touch [select name="variable_913" value="did not|did"] elicit hyperesthesia or allodynia. Sensation over lateral thigh and medial thigh [select name="variable_917" value="were normal|were absent|slightly decreased"] [text name="variable_918" default="."] trendelenburg test [select name="variable_919" value="did not|did"] cause pelvic tilt, weakness or pain. [text name="variable_920" default="."] Logroll test [select name="variable_p18" value="is negative.|is positive right side.|is positive left side.|is positive bilaterally."] [text name="variable_b69" default=""] [/conditional][conditional field="UU3" condition="(UU3).is('KNEE')"]
Inspection of both knee for gross deformity, gross effusion, echymosis and laterally displaced patella
[select name="variable_CC51" value="was negative bilaterraly|had|"] [text name="variable_CC52" default="."] there is [select name="variable_CC54" value="no|antalgic|shuffling|wide base|varus thrust|flexed knee gait|"] gait abnormality[text name="variable_CC55" default="."]
in palpation of patellar tendon, medial joint line, lateral joint line, pes anserine, knee bursa, quad tendon, IT band, LCL ligament, MCL ligament, popliteal fossa [select name="variable_CC57" value="no abnormality noted|no tenderness noted|has tenderness over|"] [text name="variable_CC58" default="."]
range of motion in flexion, extension, internal and external rotation [select name="variable_CC60" value="is normal bilaterally|limited over|is limited and painful over|is limited and not painful|is not limited but painful|"] [text name="variable_CC61" default="."]
patellar apprehenson test [select value="negative|positive"]
varus test [select value="negative|positive"]
valgus test [select value="negative|positive"]
lachman's test [select value="negative|positive"]
anterior drawer test [select value="negative|positive"]
posterior drawer test [select value="negative|POSITIVE"]
McMurray's test [select value="negative|positive"] [text name="variable_CC63" default="."][/conditional][conditional field="UU3" condition="(UU3).is('ANKLE & FOOT')"]
Inspection of both ankles for gross deformity, effusion, swelling, ecchymosis, bruises, abnormal hair loss and redness [select name="cx1" value="did not reveal any abnormality|revealed|showed|"] [select name="cx3" value="bilaterally|over left side|over right side|"] [text name="cx2" default="."]
Feet inspection has [checkbox value="normal height of plantar arches with weight bearing|high arches with weight bearing|reduced plantar arch heights with weight bearing|complete collapse of plantar arches with weight bearing|right hallux valgus|left hallux valgus|right hallux varus|left hallux varus"] [text name="cx4" default="."]
[select value="no gait abnormalities noted|Gait assessment:"] [checkbox value="antalgic but able to bear weight|unable to weight bear on right ankle|unable to weight bear over left ankle|unable to weight bear over both ankles|unable to weight bear over left foot|unable to weight bear over right foot|unable to weight bear over both feet"] [text name="cx5" default="."]
in palpation of distal fibula, anterior talofibular ligament (ATFL), posterior talofibular ligament (PTFL), calcaneal fibular ligament (CFL), distal tibia/lateral malleolus, medial malleolus, deltoid ligament complex, base of 5th metatarsal, dorsal aspect of navicular bone, proximal fibula, retro-calcaneal bursa, calcaneal bursa and medial malleus bursa [select name="cx6" value="did not cause tenderness|caused tenderness over|severe tenderness over"] [text name="cx7" default="."]
Range of motion of ankles flexion, extension, ankle inversion and ankle everson [select value="not limited & not painful|limited and painful bilaterally|reduced and painful over left side|reduced and painful over left side"] [text name="cx8" default="."] range of motion in feet on hallux flexion, hallux extension, flexion of lesser toes, extension of lesser toes, foot inversion and version"] [select name="cx20" value="are within normal limits|reduced over|restricted over"] [text name="cx21" default="."]
Talar tilt test [select name="cx9" value="negative bilaterally|positive left side|positive right side"]
Anterior drawer test [select name="cx10" value="negative bilaterally|positive left side|positive right side"]
Squeeze test [select name="cx11" value="negative bilaterally|positive left side|positive right side"]
Ankle External Rotation Test (Syndesmotic Stress Test) [select name="cx12" value="negative bilaterally|positive left side|positive right side"]
Thompson test [select value="negative|positive"] [text name="variable_CC70" default="sample text"] [/conditional] [select name="UU4" value="|HEAD & FACE|NECK|UPPER BACK|LOWER BACK|SHOULDER|ELBOW|WRIST|HIP|KNEE|ANKLE & FOOT"] [conditional field="UU4" condition="(UU4).is('HEAD & FACE')"]
Power is [select name="variable_150" value="normal bilaterally|weak bilaterally|weak right side|weak left side"] [text name="variable_power1" default="."]Sensation to light touch is [select name="variable_151" value="intact and equal bilaterally|decreased over left side|decreased over right side"][text name="variable_power2" default="."]there [select name="variable_152" value="is no|is"] hyperesthesia,hypoesthesia, allodynia. in palpation over TMJ regions, supraorbital, infraorbital, temporal, lesser and greater occipital nerve, Splenius Capitus and sternocleidomastoid muscle [select name="variable_154" value="are non tender|reveled tenderness over"] [text name="variable_155" default="."] [/conditional] [conditional field="UU4" condition="(UU4).is('NECK')"]
Inspection of the neck and cervical spine for signs of muscle spasm, muscle wasting and skin changes [select name="variable_747" value="was normal|revealed|"] [text name="variable_b60" default="."]palpation of neck and cervical area mainly over cervical spinous process and para-vertebral muscles [select name="variable_745" value="were normal|There is tenderness over|"] [text name="variable_748" default=""]. cervical range of motion in forward flexion, Extension, right and left Lateral bending [select name="variable_7" value="are within acceptable ranges|decreased|are limited in all directions|restricted|are normal but reports pain on|are normal"] [text name="variable_b61" default="."] strength checked with resisted internal rotation, external rotation, resisted flexion and extension [select name="variable_767" value="was within normal limits|revealed weakness over"] [text name="variable_768" default="."] Atlanto-axial compression (Spurling) test [select name="variable_760" value="was negative|was positive|caused pain|caused pain over right side|caused pain over left side"][text name="variable_power3" default="."]Light touch of face and neck [select name="variable_762" value="did not reveal|showed"] allodynia/hypoesthesia [text name="variable_b63" default="."] [/conditional]
[conditional field="UU4" condition="(UU4).is('SHOULDER')"]
Inspection of both exposed shoulders from front and back for asymmetry, atrophy, swelling, ecchymosis, deformity and venous distention [select name="variable_p8" value="was normal|was positive for"] [text name="variable_158" default="."]
apprehension test for shoulder stability was [select name="variable_159" value="negative bilaterally| positive right side| positive left side|positive bilaterally"].
palpation over sternoclavicular joint, clavicle, AC joint, bicipital groove, glenohumeral joint, anterior subacromial space, posterior subacromial space, rotator cuff tendons, spinous process and paraspinous muscles [select name="variable_161" value="did not elicit tenderness| caused tenderness over"] [text name="variable_691" default="."]
Range of motion performed actively and passively in forward flexion, extension, abduction, external rotation, internal rotation and horizontal abduction [select name="variable_CC1" value="are within acceptable range|limited over|limited in all directions"] [text name="variable_b65" default="."]
strength checked with resisted internal rotation, external rotation, resisted abduction and adduction are [select name="variable_170" value="within normal limits| revealed weakness over"] [text name="variable_171" default="."]
exam for biceps tendons [select name="variable_172" value="was negative bilaterally| was positive over right shoulder| was positive over left shoulder|was positive bilaterally"].
impingement test [select name="variable_173" value="was negative| was positive over right shoulder| was positive over left shoulder|was positive both shoulders"].
Labrum grind test was [select name="variable_174" value="negative| positive"] [text name="variable_b66" default="."]
[/conditional][conditional field="UU4" condition="(UU4).is('ELBOW')"]
Inspection for gross deformity, edema/swelling, effusion, echymosis and skin changes [select name="variable_CC2" value="did not reveal abnormality|was normal|has"] [text name="variable_CC3" default="."]
Palpation of olecranon, antecubital fossa, medial epicondyle and lateral epicondyle [select name="variable_CC5" value="had no tenderness|were normal|revealed tenderness over"] [text name="variable_CC6" default="."]
Range of motion in flexion and extension [select name="variable_CC7" value="were full and not painful|were full but painful|limited|limited and painful"] [text name="variable_CC8" default="."] [/conditional][conditional field="UU4" condition="(UU4).is('WRIST')"]
Inspection for gross deformity, skin changes, deviation and swelling [select name="variable_CC9" value="are normal|has|"] [text name="variable_CC10" default="."]
Palpation of dorsal aspect, volar aspect, medial aspect and lateral aspect of both wrists [select name="variable_CC12" value="looks normal|has|"] [text name="variable_CC13" default="."]
Range of motion in flexion, extension, abduction and adduction [select name="variable_CC14" value="are within normal limits and not painful|within normal limits and painful|limited|limited and not painful|limited and painful "] [text name="variable_CC15" default="."]
-Tinel's test [select value="negative|positive"]
-Phalen's test [select value="negative|positive"]
-Reverse phalen's test [select value="negative|positive"]
-Finklestein's test [select value="negative|positive"]
[text name="variable_CC17" default="."] [/conditional][conditional field="UU4” condition="(UU4).is('UPPER BACK')"]
Inspection of upper back for gross deformity, left and right paraspinal muscle spasm, spinal curvature, step-off deformity and scapular wing [select name="variable_CC19" value="was normal|has abnormality over|"] [text name="variable_CC20" default="."]
[select name="variable_CC21" value="no|there is antalgic|there is shuffling|"] gait abnormality [text name="variable_CC22" default="."]
in palpation of right first rib, left first rib, right and left paraspinal muscles, midline spinous processes, right and left trapezius [select name="variable_CC23" value="were normal|had no tenderness|had tenderness over|had tender points over|"] [text name="variable_CC24" default="."]
Range of motion of thoracolumbar in flexion, extension, right and left side-bend, right and left rotation [select name="variable_CC25" value="are normal|normal and painful|limited on|"] [text name="variable_CC26" default="."]
Spurling's test [select value="negative b/l|positive right side|positive left side|positive bilaterally"].
axial compression test [select name="variable_CC28" value="negative b/l|positive right side|positive left side|positive bilaterally"][/conditional]
[conditional field="UU4" condition="(UU4).is('LOWER BACK')"]Inspection of entire back for redness, asymmetry, deformity, scoliosis, hair growth and step off deformity [select name="variable_p9" value="did not reveal abnormalities| |showed"] [text name="variable_p10" default="."]
palpation for areas of tenderness over Spinous processus, paraspinous muscles and paravertebral muscles [select name="variable_p12" value="did not cause tenderness|there is tenderness over|there is tenderness over sacroiliac region|there is tenderness over paraspinal muscles|there is tenderness over spinous process"] [text name="variable_17" default="."]
Range of motion performed in forward flexion, extension, lateral bending and twisting [select name="variable_CC29" value="were within acceptable ranges|normal but patient reports pain over|limited in|limited in all directions|limited and painful|reduced|reduced left side|reduced right side"] [text name="variable_p15" default="."]
strength testing with heel walking, toe walking and resisted great toe dorsiflexion [select name="variable_8" value=" did not show any weakness| showed weakness over right side| showed weakness over left side|showed weakness bilaterally|cannot be assessed|"] [text name="variable_p13" default="."]
neurologic exam of deep tendon reflexes over knee and ankle [select name="variable_9" value="within normal limits|2+ and symmetric|1+ and symmetric|weak bilaterally|weak right side|weak left side|"] [text name="variable_CC30" default="."]
Straight-leg raise for sciatic nerve is [select name="variable_p14" value="negative|Positive"] [select name="variable_11" value="bilaterally|right side|left side"] [text name="variable_674" default=""].
Sacroiliac test [select name="variable_15" value="did not elicited|elicit"] SI joint pain [select name="variable_p16" value="bilaterally|over left side|over right side"], Piriformis test was [select name="variable_CC50" value="negative bilaterally|positive bilaterally|positive over right side|positive over left side"] [/conditional] [conditional field="UU4" condition="(UU4).is('HIP')"]
Inspection of hip from front and back had [select name="variable_900" value="normal|anthalgic|wide base|normal with slow get up and go"] gait and [select name="variable_901" value="had no asymmetry or atrophy|some asymetry noted over|atrophy noted over|"] [text name="variable_902" default="."] Palpation of anterior hip joint, anterior superior iliac spine, anterior inferior iliac spine, greater trochanters, iliotibial bands, gluteus muscle area, ischial bursa and trochanteric bursa [select name="variable_904" value="did not illicit tenderness|caused tenderness over|were not tender but patient reported pain on deep palpation of|"] [text name="variable_905" default="."]
Range of motion performed on internal rotation, external rotation, flexion, extension, abduction and adduction
[select name="variable_CC40" value="are normal|are within normal limits|limited and painful over|limited and not painful over|"] [text name="variable_914" default="."] strengths examination [select name="variable_912" value="within normal limits bilaterally|revealed weakness bilaterally|revealed weakness left side|revealed weakness right side"]. [text name="variable_915" default="."] Light touch [select name="variable_913" value="did not|did"] elicit hyperesthesia or allodynia. Sensation over lateral thigh and medial thigh [select name="variable_917" value="were normal|were absent|slightly decreased"] [text name="variable_918" default="."] trendelenburg test [select name="variable_919" value="did not|did"] cause pelvic tilt, weakness or pain. [text name="variable_920" default="."] Logroll test [select name="variable_p18" value="is negative.|is positive right side.|is positive left side.|is positive bilaterally."] [text name="variable_b69" default=""] [/conditional][conditional field="UU4" condition="(UU4).is('KNEE')"]
Inspection of both knee for gross deformity, gross effusion, echymosis and laterally displaced patella
[select name="variable_CC51" value="was negative bilaterraly|had|"] [text name="variable_CC52" default="."] there is [select name="variable_CC54" value="no|antalgic|shuffling|wide base|varus thrust|flexed knee gait|"] gait abnormality[text name="variable_CC55" default="."]
in palpation of patellar tendon, medial joint line, lateral joint line, pes anserine, knee bursa, quad tendon, IT band, LCL ligament, MCL ligament, popliteal fossa [select name="variable_CC57" value="no abnormality noted|no tenderness noted|has tenderness over|"] [text name="variable_CC58" default="."]
range of motion in flexion, extension, internal and external rotation [select name="variable_CC60" value="is normal bilaterally|limited over|is limited and painful over|is limited and not painful|is not limited but painful|"] [text name="variable_CC61" default="."]
patellar apprehenson test [select value="negative|positive"]
varus test [select value="negative|positive"]
valgus test [select value="negative|positive"]
lachman's test [select value="negative|positive"]
anterior drawer test [select value="negative|positive"]
posterior drawer test [select value="negative|POSITIVE"]
McMurray's test [select value="negative|positive"] [text name="variable_CC63" default="."][/conditional][conditional field="UU4" condition="(UU4).is('ANKLE & FOOT')"]
Inspection of both ankles for gross deformity, effusion, swelling, ecchymosis, bruises, abnormal hair loss and redness [select name="cx1" value="did not reveal any abnormality|revealed|showed|"] [select name="cx3" value="bilaterally|over left side|over right side|"] [text name="cx2" default="."]
Feet inspection has [checkbox value="normal height of plantar arches with weight bearing|high arches with weight bearing|reduced plantar arch heights with weight bearing|complete collapse of plantar arches with weight bearing|right hallux valgus|left hallux valgus|right hallux varus|left hallux varus"] [text name="cx4" default="."]
[select value="no gait abnormalities noted|Gait assessment:"] [checkbox value="antalgic but able to bear weight|unable to weight bear on right ankle|unable to weight bear over left ankle|unable to weight bear over both ankles|unable to weight bear over left foot|unable to weight bear over right foot|unable to weight bear over both feet"] [text name="cx5" default="."]
in palpation of distal fibula, anterior talofibular ligament (ATFL), posterior talofibular ligament (PTFL), calcaneal fibular ligament (CFL), distal tibia/lateral malleolus, medial malleolus, deltoid ligament complex, base of 5th metatarsal, dorsal aspect of navicular bone, proximal fibula, retro-calcaneal bursa, calcaneal bursa and medial malleus bursa [select name="cx6" value="did not cause tenderness|caused tenderness over|severe tenderness over"] [text name="cx7" default="."]
Range of motion of ankles flexion, extension, ankle inversion and ankle everson [select value="not limited & not painful|limited and painful bilaterally|reduced and painful over left side|reduced and painful over left side"] [text name="cx8" default="."] range of motion in feet on hallux flexion, hallux extension, flexion of lesser toes, extension of lesser toes, foot inversion and version"] [select name="cx20" value="are within normal limits|reduced over|restricted over"] [text name="cx21" default="."]
Talar tilt test [select name="cx9" value="negative bilaterally|positive left side|positive right side"]
Anterior drawer test [select name="cx10" value="negative bilaterally|positive left side|positive right side"]
Squeeze test [select name="cx11" value="negative bilaterally|positive left side|positive right side"]
Ankle External Rotation Test (Syndesmotic Stress Test) [select name="cx12" value="negative bilaterally|positive left side|positive right side"]
Thompson test [select value="negative|positive"] [text name="variable_CC70" default="sample text"] [/conditional]


IMPRESSION
1- [select name="variable_1442" value=" |Lumbar Degenerative Disk Disease|Right Sciatica Radiculopathy|Left Sciatica Radiculopathy|Bilateral Sciatica Radiculopathy|Lumbar Facet Joint Arthritis|Cervical Facet Joint Arthritis|Thoracic Facet Joint Arthritis|Sacroiliitis|Lumbar Spinal Stenosis|Thoracic Spinal Stenosis|Cervical Spinal Stenosis|Piriformis syndrome|Cervical Osteoarthritis|Cervical DDD|Cervical DDD with radiculopathy|Left shoulder osteoarthritis|Right shoulder Osreoarthritis|Bilateral shoulder osteoarthritis|Left rotator cuff injury|right rotator cuff injury|bilateral rotator cuff injury|Hip Osteoarthritis bilateral|Hip Osteoarthritis Left|Hip Osteoarthritis Right|Migraine Headache|Occipital Neuralgia|Right Carpal Tunnel Syndrome|Left Carpal Tunnel Syndrome|Bilateral Carpal Tunnel Syndrome|Neuropathic Pain"]
2- [select name="variable_1443" value=" |Lumbar Degenerative Disk Disease|Right Sciatica Radiculopathy|Left Sciatica Radiculopathy|Bilateral Sciatica Radiculopathy|Lumbar Facet Joint Arthritis|Cervical Facet Joint Arthritis|Thoracic Facet Joint Arthritis|Sacroiliitis|Lumbar Spinal Stenosis|Thoracic Spinal Stenosis|Cervical Spinal Stenosis|Piriformis syndrome|Cervical Osteoarthritis|Cervical DDD|Cervical DDD with radiculopathy|Left shoulder osteoarthritis|Right shoulder Osreoarthritis|Bilateral shoulder osteoarthritis|Left rotator cuff injury|right rotator cuff injury|bilateral rotator cuff injury|Hip Osteoarthritis bilateral|Hip Osteoarthritis Left|Hip Osteoarthritis Right|Migraine Headache|Occipital Neuralgia|Right Carpal Tunnel Syndrome|Left Carpal Tunnel Syndrome|Bilateral Carpal Tunnel Syndrome|Neuropathic Pain"]
3- [select name="variable_1444" value=" |Lumbar Degenerative Disk Disease|Right Sciatica Radiculopathy|Left Sciatica Radiculopathy|Bilateral Sciatica Radiculopathy|Lumbar Facet Joint Arthritis|Cervical Facet Joint Arthritis|Thoracic Facet Joint Arthritis|Sacroiliitis|Lumbar Spinal Stenosis|Thoracic Spinal Stenosis|Cervical Spinal Stenosis|Piriformis syndrome|Cervical Osteoarthritis|Cervical DDD|Cervical DDD with radiculopathy|Left shoulder osteoarthritis|Right shoulder Osreoarthritis|Bilateral shoulder osteoarthritis|Left rotator cuff injury|right rotator cuff injury|bilateral rotator cuff injury|Hip Osteoarthritis bilateral|Hip Osteoarthritis Left|Hip Osteoarthritis Right|Migraine Headache|Occipital Neuralgia|Right Carpal Tunnel Syndrome|Left Carpal Tunnel Syndrome|Bilateral Carpal Tunnel Syndrome|Neuropathic Pain"]
4- [select name="variable_1445" value=" |Lumbar Degenerative Disk Disease|Right Sciatica Radiculopathy|Left Sciatica Radiculopathy|Bilateral Sciatica Radiculopathy|Lumbar Facet Joint Arthritis|Cervical Facet Joint Arthritis|Thoracic Facet Joint Arthritis|Sacroiliitis|Lumbar Spinal Stenosis|Thoracic Spinal Stenosis|Cervical Spinal Stenosis|Piriformis syndrome|Cervical Osteoarthritis|Cervical DDD|Cervical DDD with radiculopathy|Left shoulder osteoarthritis|Right shoulder Osreoarthritis|Bilateral shoulder osteoarthritis|Left rotator cuff injury|right rotator cuff injury|bilateral rotator cuff injury|Hip Osteoarthritis bilateral|Hip Osteoarthritis Left|Hip Osteoarthritis Right|Migraine Headache|Occipital Neuralgia|Right Carpal Tunnel Syndrome|Left Carpal Tunnel Syndrome|Bilateral Carpal Tunnel Syndrome|Neuropathic Pain"]
5- [select name="variable_1446" value=" |Lumbar Degenerative Disk Disease|Right Sciatica Radiculopathy|Left Sciatica Radiculopathy|Bilateral Sciatica Radiculopathy|Lumbar Facet Joint Arthritis|Cervical Facet Joint Arthritis|Thoracic Facet Joint Arthritis|Sacroiliitis|Lumbar Spinal Stenosis|Thoracic Spinal Stenosis|Cervical Spinal Stenosis|Piriformis syndrome|Cervical DDD|Cervical DDD with radiculopathy|Left shoulder osteoarthritis|Right shoulder Osreoarthritis|Bilateral shoulder osteoarthritis|Left rotator cuff injury|right rotator cuff injury|bilateral rotator cuff injury|Hip Osteoarthritis bilateral|Hip Osteoarthritis Left|Hip Osteoarthritis Right|Migraine Headache|Occipital Neuralgia|Right Carpal Tunnel Syndrome|Left Carpal Tunnel Syndrome|Bilateral Carpal Tunnel Syndrome|Neuropathic Pain"]
[textarea name="variable_1447" default=""]

Treatment Plan:
Patient treatment is considered in three domains: interventional, pharmacological, and patient-centric recommendations. With this in mind the following recommendations are suggested:

Patient-centric Recommendations:
[text name="variable_670" default=""]
[select name="variable_680" value="He|She"] [select name="variable_681" value="has done|is doing|is going to do"] [checkbox name="variable_671" value="no physical therapy|physiotherapy|massage therapy|chiropractic therapy|thai chi exercises|aquatic exercises|yoga|acupuncture|Tens therapy|does exercises at home|We had a discussion about effects of physical therapy on pain management|and states none of them helped with pain|and states physical therapy gives temporary relief|.Patient cannot afford physical therapy due to financial limitations."]
[text name="variable_672" default=""]
[checkbox name="variable_614" value="I advised to increase physical activities. Maintaining good posture and its effect on pain discussed. Discussed heat and ice, massage, postural exercises such as walking/swimming 3 times a week for at least 40 minutes, stretching and strengthening exercises and staying active.
|I recommended the patient to initiate a weight loss program and increase physical conditioning with an emphasis on core strength and gradual increase in exercise as tolerated. Commencing a weight loss program (weight watchers, Atkins diet...) offered to patient.|We also discussed about the fact that patients with chronic pain often try to protect the area that hurts by avoiding movements that exacerbates the pain and causes muscle atrophy, pain in tendons and connective tissue, loss of muscle strength and as a consequence there would be tendon and connective tissue pain. All this can be prevented with regular 20 minutes aerobic and 30 minutes weight bearing 5 days a week. I tried to encourage your patient to do more physical activities in spite of feeling pain.|I said we need to pump blood into the area that hurts and also pumping back to waste products that have been building up. Some patients do not need any medications or injections with just doing this.|We had a discussion about endurance of physical therapy as an important mainstays of this therapy. I also discussed about possible worsening of the pain at the beginning due to muscle weakness and is expected to get better with continuing of physical therapy.|I discussed about the importance of working on balance, stretching, range of motion and strengthening in physical therapy. Stretching by itself can lead to increase in range of motion and maintains functional ability. Yoga and tai-chi exercises are very good treatments to achieve these goals.|Therapeutic heat as it commonly used. Heat increases extensibility of collagen tissue decreases joint stiffness and improve muscle spasm on the other side stimulants more receptors and decreasing activation of nociceptors. It also increases blood flow which helps resolve the inflammatory infiltrate and edema. Aqua therapy exercises specifically in warm water has been reported by patients as a good approach for pain reduction. We have several sites for this aqua therapy both public and private in community.|Therapeutic massage which is often used for pain relief and in muscle relaxation. Massage releases muscle tension, promote relaxation, improving circulation and enhances tissue perfusion and oxygenation. This allows for the removal of lactic acid and other toxins from muscle tissue. Therapeutic massage may also help alleviate the pain caused by fibrous scar tissue.|Therapeutic ultrasound and TENS which has a mechanism of deep heating that leads to increased blood flow and reduction in muscle spasm, and increase extensibility of collagen fiber.|Acupuncture therapy works mostly on balancing energy and whole body. Research has shown that acupuncture releases endogenous opioids, and that the same opioid that are released with running. Acupuncture may also activate large myelinated fibers that causes inhibitory effects on pain.|Chronic Pain Self-Management program. This program is free of charge and runs two hours per week for six weeks. It focuses on assisting patients on improving self-awareness with pain perceptions and subsequent actions. Your patient has been given further information regarding the program. Hypnosis, mindfulness and meditation or other modalities of relaxation that helps to decrease the pain perceptions.|Cognitive behavioral therapy is also effective since pain is a complex experience that is influenced not only by its underlying pathophysiology but also by an individual's cognition. Cognitive behavioral therapy attempts to alter the psychological principles governing pain including patient’s beliefs, emotions, behavioral reactions and expectations. CBT is typically carried out in a small group sessions of 3-6 patients that are held weekly for 8-10 weeks. The group are typically led by a psychologist.|Biofeedback is a practice of providing information to the patient about unconscious physiologic processes such as heart rate and muscle tension. This form of therapy involves instrumentation that tracks specific physiologic indication of tension in the body. The most common form of biofeedback involves using electromyographic feedback from the affected region. It is helpful in low back pain and headache related to myofascial spasm."][textarea name="variable_1755" default=""]

Pharmacological Options:
[select name="variable_660" value="He|She|I"] [select name="variable_662" value="has tried|is taking|has not tried|Offered"] [checkbox name="variable_661" value="tylenol|different types of NSAIDS|advil|naproxen|meloxicam|gabapentin|lyrica|cymbalta|elavil|tramadol|tylenol 1|tylenol 2|tylenol 3|tylenol 4|percocet|hydromorphone IR|hydromorphone CR|dilaudid|morphine IR|morphine SR|butrans patch|fentanyl patch|Suboxone|medical cannabis inhalation|cannabis Oil"] [select name="variable_663" value="|in the past for chronic pain management|at the moment"]. [text name="variable_693" default=""]
[select name="IP1" value="|I offered"] [select name="Q1" value="|Naproxen|advil|Meloxicam|toradol|percocet|oxycodone IR|oxycodone CR|hydromorphone IR|hydromorphone CR|butrans|Lyrica|gabapentin|cymbalta|amitriptyline|nortriptyline"][conditional field="Q1" condition="(Q1).is('Naproxen')"] , side effects like The most common adverse reactions involve gastrointestinal damage, ranging from patient discomfort to potentially fatal gastrointestinal ulceration, bleeding and perforation. Less common but serious cardiovascular, dermatologic, hypersensitivity and renal reactions may occur. Nausea, dyspepsia, diarrhea, anorexia, flatulence, Perforation, ulceration, bleeding in upper and lower GI tract, Prolonged bleeding time and anemia.
[/conditional][conditional field="Q1" condition="(Q1).is('advil')"] , side effects like The most common adverse reactions involve gastrointestinal damage, ranging from patient discomfort to potentially fatal gastrointestinal ulceration, bleeding and perforation. Less common but serious cardiovascular, dermatologic, hypersensitivity and renal reactions may occur. Nausea, dyspepsia, diarrhea, anorexia, flatulence, Perforation, ulceration, bleeding in upper and lower GI tract, Prolonged bleeding time and anemia.
[/conditional][conditional field="Q1" condition="(Q1).is('Meloxicam')"] ,side effects like The most common adverse reactions involve gastrointestinal damage, ranging from patient discomfort to potentially fatal gastrointestinal ulceration, bleeding and perforation. Less common but serious cardiovascular, dermatologic, hypersensitivity and renal reactions may occur. Nausea, dyspepsia, diarrhea, anorexia, flatulence, Perforation, ulceration, bleeding in upper and lower GI tract, Prolonged bleeding time and anemia.
[/conditional][conditional field="Q1" condition="(Q1).is('toradol')"] ,side effects like The most common adverse reactions involve gastrointestinal damage, ranging from patient discomfort to potentially fatal gastrointestinal ulceration, bleeding and perforation. Less common but serious cardiovascular, dermatologic, hypersensitivity and renal reactions may occur. Nausea, dyspepsia, diarrhea, anorexia, flatulence, Perforation, ulceration, bleeding in upper and lower GI tract, Prolonged bleeding time and anemia.
[/conditional][conditional field="Q1" condition="(Q1).is('percocet')"] ,The major hazards include respiratory depression, central nervous system depression and apnea. To a lesser degree, circulatory depression, respiratory arrest, shock and cardiac arrest have occurred. The most frequently observed adverse effects are constipation, light-headedness, dizziness, sedation, nausea, vomiting, and hyperhidrosis. Avoiding concomitant use of opioids with other sedative medication discussed due to over sedation concerns.
[/conditional][conditional field="Q1" condition="(Q1).is('oxycodone IR')"] ,The major hazards include respiratory depression, central nervous system depression and apnea. To a lesser degree, circulatory depression, respiratory arrest, shock and cardiac arrest have occurred. The most frequently observed adverse effects are constipation, light-headedness, dizziness, sedation, nausea, vomiting, and hyperhidrosis explained to patient. Avoiding concomitant use of opioids with other sedative medication discussed due to over sedation concerns.
[/conditional][conditional field="Q1" condition="(Q1).is('oxycodone CR')"] ,The major hazards include respiratory depression, central nervous system depression and apnea. To a lesser degree, circulatory depression, respiratory arrest, shock and cardiac arrest have occurred. The most frequently observed adverse effects are constipation, light-headedness, dizziness, sedation, nausea, vomiting, and hyperhidrosis explained to patient. Avoiding concomitant use of opioids with other sedative medication discussed due to over sedation concerns.
[/conditional][conditional field="Q1" condition="(Q1).is('hydromorphone IR')"] ,The major hazards include respiratory depression, central nervous system depression and apnea. To a lesser degree, circulatory depression, respiratory arrest, shock and cardiac arrest have occurred. The most frequently observed adverse effects are constipation, light-headedness, dizziness, sedation, nausea, vomiting, and hyperhidrosis explained to patient. Avoiding concomitant use of opioids with other sedative medication discussed due to over sedation concerns.
[/conditional][conditional field="Q1" condition="(Q1).is('hydromorphone CR')"] ,The major hazards include respiratory depression, central nervous system depression and apnea. To a lesser degree, circulatory depression, respiratory arrest, shock and cardiac arrest have occurred. The most frequently observed adverse effects are constipation, light-headedness, dizziness, sedation, nausea, vomiting, and hyperhidrosis explained to patient. Avoiding concomitant use of opioids with other sedative medication discussed due to over sedation concerns.
[/conditional][conditional field="Q1" condition="(Q1).is('Lyrica')"] ,verbal consent taken and information about side effects like Fatigue, weight gain, peripheral edema, dyspepsia, sleepiness, dizziness, peripheral edema, dry mouth and anaphylaxis reaction discussed with patient. Adverse events were usually mild to moderate in intensity based on dose and happens at first 1-2 weeks of commencing lyrica.
[/conditional][conditional field="Q1" condition="(Q1).is('gabapentin')"] ,verbal consent taken and information about side effects like Fatigue, weight gain, peripheral edema, dyspepsia, sleepiness, dizziness, tremor, pruritus. Diplopia and anaphylaxis reaction. discussed with patient. Adverse events were usually mild to moderate in intensity, dose related and happens at first 1-2 weeks of commencing gabapentin.
[/conditional][conditional field="Q1" condition="(Q1).is('cymbalta')"] ,Cymbalta is usually taken once a day. capsules may be taken with or without food; however, food may help reduce the incidence of initial nausea, While patients may notice improvement with therapy in 1 to 4 weeks, advised to continue therapy for several months or longer as directed.
Patients advised that they may experience new or worsened feelings of agitation, hostility, anxiety, impulsivity, or thoughts about suicide, self-harm or harm to others, particularly in the first few weeks of treatment or when doses are adjusted, advise patients to not discontinue Cymbalta on their own due to withdrawal symptoms such as dizziness, nausea, diarrhea, headache, paresthesia, vomiting, irritability, anxiety, excessive sweating, fatigue, insomnia, and nightmare. Patients informed that severe liver problems, sometimes fatal, have been reported in patients treated with Cymbalta, advised to keep use of alcohol to a minimum, may cause an increase in blood pressure, risk of bleeding associated with the concomitant use with NSAIDS, ASA, or other drugs that affect coagulation. Other rare complications like Serotonin Syndrome/Neuroleptic Malignant Syndrome, Hyponatremia, Urinary Hesitation and Retention, Bone Fractures, Serious Skin Reactions discussed.
[/conditional][conditional field="Q1" condition="(Q1).is('amitriptyline')"] ,Major side effects of TCA like orthostatic hypotension, ventricular arrhythmias, heart block, Sexual dysfunction ( impaired arousal and orgasm), Weight gain, Anticholinergic effects of blurred vision, cognitive impairment, confusion, constipation, dry mouth, urinary retention and sedation discussed with patient.
[/conditional][conditional field="Q1" condition="(Q1).is('nortriptyline')"] ,Major side effects of TCA like orthostatic hypotension, ventricular arrhythmias, heart block, Sexual dysfunction ( impaired arousal and orgasm), Weight gain, Anticholinergic effects of blurred vision, cognitive impairment, confusion, constipation, dry mouth, urinary retention and sedation discussed with patient.
[/conditional][conditional field="Q1" condition="(Q1).is('butrans')"], The major hazards include respiratory depression, central nervous system depression and apnea. To a lesser degree, circulatory depression, respiratory arrest, shock and cardiac arrest have occurred. The most frequently observed adverse effects are constipation, light-headedness, dizziness, sedation, nausea, vomiting, and hyperhidrosis. Avoiding concomitant use of opioids with other sedative medication discussed due to over sedation concerns.[/conditional][select name="IP2" value="|patient accepted to take this medication after verbal consent|patient is not interested in this medication|patient is not interested in adding any medication and asks for another management option"]
[select name="IP9" value="|I prescribed|I authorized"] [text name="IP4" default=""] [select name="IP5" value="|0.25|0.5|1|1.5|2|2.5|3|3.5|4|4.5|5|5/325|6|7|8|9|10|12|12.5|15|20|25|30|35|40|45|50|60|70|75|80|90|10|125|150|175|200|225|250|300|350|375|400|450|475|500|525|550|575|600|750|900|1000|1200|1500|"] [select name="IP6" value="|mg|ml|gram|microgram|patch"] [select name="IP8" value="|PO|inhale|im|dermal|patch"] [select name="IP7" value="|OD|BID|TID|QID|QHS|four times daily|five times daily|six times daily|every two days|every three days|PRN"] [select name="IP11" value="|and PRN"] [select name="IP10" value="|for one week|for two weeks|for 3 weeks|for a month|for two months|for three months|for six months|for twelve months"]
[textarea name="IP3" default=""]

[select name="I1" value="|I offered"] [select name="y1" value="|Naproxen|advil|Meloxicam|toradol|percocet|oxycodone IR|oxycodone CR|hydromorphone IR|hydromorphone CR|butrans|Lyrica|gabapentin|cymbalta|amitriptyline|nortriptyline"][conditional field="y1" condition="(y1).is('Naproxen')"] , side effects like The most common adverse reactions involve gastrointestinal damage, ranging from patient discomfort to potentially fatal gastrointestinal ulceration, bleeding and perforation. Less common but serious cardiovascular, dermatologic, hypersensitivity and renal reactions may occur. Nausea, dyspepsia, diarrhea, anorexia, flatulence, Perforation, ulceration, bleeding in upper and lower GI tract, Prolonged bleeding time and anemia.
[/conditional][conditional field="y1" condition="(y1).is('advil')"] , side effects like The most common adverse reactions involve gastrointestinal damage, ranging from patient discomfort to potentially fatal gastrointestinal ulceration, bleeding and perforation. Less common but serious cardiovascular, dermatologic, hypersensitivity and renal reactions may occur. Nausea, dyspepsia, diarrhea, anorexia, flatulence, Perforation, ulceration, bleeding in upper and lower GI tract, Prolonged bleeding time and anemia.
[/conditional][conditional field="y1" condition="(y1).is('Meloxicam')"] ,side effects like The most common adverse reactions involve gastrointestinal damage, ranging from patient discomfort to potentially fatal gastrointestinal ulceration, bleeding and perforation. Less common but serious cardiovascular, dermatologic, hypersensitivity and renal reactions may occur. Nausea, dyspepsia, diarrhea, anorexia, flatulence, Perforation, ulceration, bleeding in upper and lower GI tract, Prolonged bleeding time and anemia.
[/conditional][conditional field="y1" condition="(y1).is('toradol')"] ,side effects like The most common adverse reactions involve gastrointestinal damage, ranging from patient discomfort to potentially fatal gastrointestinal ulceration, bleeding and perforation. Less common but serious cardiovascular, dermatologic, hypersensitivity and renal reactions may occur. Nausea, dyspepsia, diarrhea, anorexia, flatulence, Perforation, ulceration, bleeding in upper and lower GI tract, Prolonged bleeding time and anemia.
[/conditional][conditional field="y1" condition="(y1).is('percocet')"] ,The major hazards include respiratory depression, central nervous system depression and apnea. To a lesser degree, circulatory depression, respiratory arrest, shock and cardiac arrest have occurred. The most frequently observed adverse effects are constipation, light-headedness, dizziness, sedation, nausea, vomiting, and hyperhidrosis. Avoiding concomitant use of opioids with other sedative medication discussed due to over sedation concerns.
[/conditional][conditional field="y1" condition="(y1).is('oxycodone IR')"] ,The major hazards include respiratory depression, central nervous system depression and apnea. To a lesser degree, circulatory depression, respiratory arrest, shock and cardiac arrest have occurred. The most frequently observed adverse effects are constipation, light-headedness, dizziness, sedation, nausea, vomiting, and hyperhidrosis explained to patient. Avoiding concomitant use of opioids with other sedative medication discussed due to over sedation concerns.
[/conditional][conditional field="y1" condition="(y1).is('oxycodone CR')"] ,The major hazards include respiratory depression, central nervous system depression and apnea. To a lesser degree, circulatory depression, respiratory arrest, shock and cardiac arrest have occurred. The most frequently observed adverse effects are constipation, light-headedness, dizziness, sedation, nausea, vomiting, and hyperhidrosis explained to patient. Avoiding concomitant use of opioids with other sedative medication discussed due to over sedation concerns.
[/conditional][conditional field="y1" condition="(y1).is('hydromorphone IR')"] ,The major hazards include respiratory depression, central nervous system depression and apnea. To a lesser degree, circulatory depression, respiratory arrest, shock and cardiac arrest have occurred. The most frequently observed adverse effects are constipation, light-headedness, dizziness, sedation, nausea, vomiting, and hyperhidrosis explained to patient. Avoiding concomitant use of opioids with other sedative medication discussed due to over sedation concerns.
[/conditional][conditional field="y1" condition="(y1).is('hydromorphone CR')"] ,The major hazards include respiratory depression, central nervous system depression and apnea. To a lesser degree, circulatory depression, respiratory arrest, shock and cardiac arrest have occurred. The most frequently observed adverse effects are constipation, light-headedness, dizziness, sedation, nausea, vomiting, and hyperhidrosis explained to patient. Avoiding concomitant use of opioids with other sedative medication discussed due to over sedation concerns.
[/conditional][conditional field="y1" condition="(y1).is('Lyrica')"] ,verbal consent taken and information about side effects like Fatigue, weight gain, peripheral edema, dyspepsia, sleepiness, dizziness, peripheral edema, dry mouth and anaphylaxis reaction discussed with patient. Adverse events were usually mild to moderate in intensity based on dose and happens at first 1-2 weeks of commencing lyrica.
[/conditional][conditional field="y1" condition="(y1).is('gabapentin')"] ,verbal consent taken and information about side effects like Fatigue, weight gain, peripheral edema, dyspepsia, sleepiness, dizziness, tremor, pruritus. Diplopia and anaphylaxis reaction. discussed with patient. Adverse events were usually mild to moderate in intensity, dose related and happens at first 1-2 weeks of commencing gabapentin.
[/conditional][conditional field="y1" condition="(y1).is('cymbalta')"] ,Cymbalta is usually taken once a day. capsules may be taken with or without food; however, food may help reduce the incidence of initial nausea, While patients may notice improvement with therapy in 1 to 4 weeks, advised to continue therapy for several months or longer as directed.
Patients advised that they may experience new or worsened feelings of agitation, hostility, anxiety, impulsivity, or thoughts about suicide, self-harm or harm to others, particularly in the first few weeks of treatment or when doses are adjusted, advise patients to not discontinue Cymbalta on their own due to withdrawal symptoms such as dizziness, nausea, diarrhea, headache, paresthesia, vomiting, irritability, anxiety, excessive sweating, fatigue, insomnia, and nightmare. Patients informed that severe liver problems, sometimes fatal, have been reported in patients treated with Cymbalta, advised to keep use of alcohol to a minimum, may cause an increase in blood pressure, risk of bleeding associated with the concomitant use with NSAIDS, ASA, or other drugs that affect coagulation. Other rare complications like Serotonin Syndrome/Neuroleptic Malignant Syndrome, Hyponatremia, Urinary Hesitation and Retention, Bone Fractures, Serious Skin Reactions discussed.
[/conditional][conditional field="y1" condition="(y1).is('amitriptyline')"] ,Major side effects of TCA like orthostatic hypotension, ventricular arrhythmias, heart block, Sexual dysfunction ( impaired arousal and orgasm), Weight gain, Anticholinergic effects of blurred vision, cognitive impairment, confusion, constipation, dry mouth, urinary retention and sedation discussed with patient.
[/conditional][conditional field="y1" condition="(y1).is('nortriptyline')"] ,Major side effects of TCA like orthostatic hypotension, ventricular arrhythmias, heart block, Sexual dysfunction ( impaired arousal and orgasm), Weight gain, Anticholinergic effects of blurred vision, cognitive impairment, confusion, constipation, dry mouth, urinary retention and sedation discussed with patient.
[/conditional][conditional field="y1" condition="(y1).is('butrans')"], The major hazards include respiratory depression, central nervous system depression and apnea. To a lesser degree, circulatory depression, respiratory arrest, shock and cardiac arrest have occurred. The most frequently observed adverse effects are constipation, light-headedness, dizziness, sedation, nausea, vomiting, and hyperhidrosis. Avoiding concomitant use of opioids with other sedative medication discussed due to over sedation concerns.
[/conditional][conditional field="y1" condition="(y1).is('4')"] [select name="I2" value="|patient accepted to take this medication after verbal consent|patient is not interested in this medication|patient is not interested in adding any medication and asks for another management option"]
[select name="I9" value="|I prescribed|I authorized"] [text name="I4" default=""] [select name="I5" value="|0.25|0.5|1|1.5|2|2.5|3|3.5|4|4.5|5|5/325|6|7|8|9|10|12|12.5|15|20|25|30|35|40|45|50|60|70|75|80|90|10|125|150|175|200|225|250|300|350|375|400|450|475|500|525|550|575|600|750|900|1000|1200|1500|"] [select name="I6" value="|mg|ml|gram|microgram|patch"] [select name="IP8" value="|PO|inhale|im|dermal|patch"] [select name="I7" value="|OD|BID|TID|QID|QHS|four times daily|five times daily|six times daily|every two days|every three days|PRN"] [select name="I11" value="|and PRN"] [select name="I10" value="|for one week|for two weeks|for 3 weeks|for a month|for two months|for three months|for six months|for twelve months"]
[textarea name="I3" default=""]
[text name="variable_665" default=""]

Interventional Options:
[select name="variable_614" value="I recommended a trial of nerve block for|I did not offer trial of nerve block for"] [checkbox name="variable_615" value="Low back pain|Upper Back Pain|Back Pain|Neck pain|Neck and shoulder pain|shoulder pain|Neuropathic pain"],[text name="variable_616" default=""]
The palliative nature of these blocks was explained to the patient. [checkbox name="variable_617" value="The patient appeared to understand and wishes to proceed with this therapy|The patient was reluctant to consider this option; we will remain available to trial this option should they have a change of opinion|I performed several blocks over Lumbar area|I performed several blocks over Neck and shoulder area|I performed some block over neck and head area for headache|patient had relief of pain after nerve blocks|I will follow patient in a week for re-asessment|I will follow patient in two weeks for re-asessment|I will follow patient in three weeks for re-asessment|I will follow patient in a month for re-asessment|Patient is on anti-coagulant and not a suitable candidate for injections, discussed with patient"].
[text name="variable_695" default=""].

Patient advised to get a Nerve block information package from front d
Consultation Date:
Patient’s name:
Date birth:
Dear Dr.
Thank you for referring this years old handed to pain care Clinic site for chronic pain assessment and management.

HISTORY OF PRESENTING COMPLAINT/S
main complaint is




.
Fibromyalgia Rapid Screening Tool: , for diagnosis of fibromyalgia. Total BPI Interference Score is


CONSULTATIONS and Other Healthcare Professionals:
PAST MEDICAL HISTORY
1. Surgical:
2. Medical:
FUNCTONAL INQUIRY
General functional inquiry including cardiovascular, respiratory, gastrointestinal, genitourinary, haematological and endocrine systems was unremarkable at the moment. No other musculoskeletal or neurological issues were reported other than the chief complaints.
PREVIOUS INVESTIGATIONS

PAST PAIN MEDICATIONS

CURRENT MEDICATIONS

The patient’s current narcotic dose is MED. This the NOUGG.
ALLERGIES
Medications:
Environmental:
SOCIAL HISTORY
The patient is currently and is Presently living . The patient has children, .The patient’s highest level of education completed is
PSYCHOLOGICAL STATUS AND RELATED MATTERS
There history of suicidal ideation and the patient previous suicide attempts. The current suicide risk is . The patient a psychiatrist. Hamilton Depression Rating Scale (HAM-D): , HAM-A consistent with for depression and for anxiety.
Smoking:
Alcohol:
Illicit drug:
Sexual function is reported . is about this issue. Sleep is generally . There latency in sleep onset with interruptions due to the pain. The patient reports . Medication utilized as a sleep aid.
ADDICTION RISK
1. Gender

display/hide references
Urine Drug Screen:
OXY TCA: AMP: MOP: BZO: MTD: BAR: MAMP: COC: THC:

PHYSICAL EXAMINATION
Age: BP: HR: Weight:
On physical exam today, I found to be , oriented to person, place and time. has communication skills, recent and remote memory . insight and judgment, affect and mood appeared , was to follow commands and cooperated with the examination. body Type is and appears conditioned. I asked to walk and gait with posture, has a get up and go.
My objective findings as related to injuries are as follows:












IMPRESSION
1-
2-
3-
4-
5-


Treatment Plan:
Patient treatment is considered in three domains: interventional, pharmacological, and patient-centric recommendations. With this in mind the following recommendations are suggested:

Patient-centric Recommendations:





Pharmacological Options:
.









Interventional Options:
,
The palliative nature of these blocks was explained to the patient. .
.

Patient advised to get a Nerve block information package from front d

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