Modified 2

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[textarea name="variable_27" default=""]  [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|coldness|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=""] 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 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 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 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 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 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 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 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 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 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=""] 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 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 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 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 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 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 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 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 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 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_jk5" value="|there is also|in addition there is also|another pain complaint is|he also has complaint of|she also has complaint of|patient has no more pain complaints today"] [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=""] 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 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 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 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 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 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"] feeling 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 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 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 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_jk5" value="|there is also|in addition there is also|another pain complaint is|he also has complaint of|she also has complaint of|patient has no more pain complaints today"] [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=""] 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 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 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 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 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 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 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 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 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 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_jk5" value="|there is also|in addition there is also|another pain complaint is|he also has complaint of|she also has complaint of|patient has no more pain complaints today"] [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=""] 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 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 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 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. 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 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 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 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 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 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_jk5" value="|there is also|in addition there is also|another pain complaint is|he also has complaint of|she also has complaint of|patient has no more pain complaints today"] [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=""] 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 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 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 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 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 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 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 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 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 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_jk5" value="|there is also|in addition there is also|another pain complaint is|he also has complaint of|she also has complaint of|patient has no more pain complaints today"] [select name="Q7" value="|headache|neck pain|upper back pain|low back pain|shoulder pain|hip pain|knee pain|ankle pain|foot pain|groin pain"][conditional field="Q7" condition="(Q7).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=""] 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="Q7" condition="(Q7).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 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="Q7" condition="(Q7).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 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="Q7” condition="(Q7).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 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="Q7" condition="(Q7).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 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="Q7" condition="(Q7).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 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="Q7" condition="(Q7).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 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="Q7" condition="(Q7).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 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="Q7" condition="(Q7).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 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="Q7" condition="(Q7).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 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].
With respect to the patient’s complaint of back pain, the patient reports [textarea name="variable_23" default=""]
[text name="variable_25" default=""] bowel or bladder dysfunction. There is [textarea name="variable_23" default=""]
[text name="variable_25" default=""] saddle anaesthesia, weakness, or radiation reported. [textarea name="variable_23" default=""]
[text name="variable_25" default=""] thoracic pain, fever, weight loss, night sweats, immunosuppression or history of carcinoma. The patient [textarea name="variable_23" default=""]
[text name="variable_25" default=""] overt trauma,[textarea name="variable_23" default=""]
[text name="variable_25" default=""] I.V. drug use,[textarea name="variable_23" default=""]
[text name="variable_25" default=""] chronic steroid use [textarea name="variable_23" default=""]
[text name="variable_25" default=""] substantive night pain.

With respect to the patient’s complaint of neck pain, the patient reports[textarea name="variable_23" default=""]
[text name="variable_25" default=""] paresthesia, weakness or radiation. [textarea name="variable_23" default=""]
[text name="variable_25" default=""] thoracic pain,[textarea name="variable_23" default=""]
[text name="variable_25" default=""] fever,[textarea name="variable_23" default=""]
[text name="variable_25" default=""] weight loss,[textarea name="variable_23" default=""]
[text name="variable_25" default=""] night sweats,[textarea name="variable_23" default=""]
[text name="variable_25" default=""] immunosuppression or history of carcinoma. The patient [textarea name="variable_23" default=""]
[text name="variable_25" default=""] overt trauma,[textarea name="variable_23" default=""]
[text name="variable_25" default=""] I.V drug use,[textarea name="variable_23" default=""]
[text name="variable_25" default=""] chronic steroid use [textarea name="variable_23" default=""]
[text name="variable_25" default=""] substantive night pain.

The patient’s headache is [textarea name="variable_23" default=""]
[text name="variable_25" default=""] associated with nausea,[textarea name="variable_23" default=""]
[text name="variable_25" default=""] vomiting,[textarea name="variable_23" default=""]
[text name="variable_25" default=""] photophobia,[textarea name="variable_23" default=""]
[text name="variable_25" default=""] phonophobia. There are [textarea name="variable_23" default=""]
[text name="variable_25" default=""] reported visual changes or aura. [textarea name="variable_23" default=""]
[text name="variable_25" default=""] 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."

The patient has [textarea name="variable_23" default=""]
[text name="variable_25" default=""] used physiotherapy,[textarea name="variable_23" default=""]
[text name="variable_25" default=""] . The patient takes[textarea name="variable_23" default=""]
[text name="variable_25" default=""] medication. The patient does[textarea name="variable_23" default=""]
[text name="variable_25" default=""] smoke marijuana.

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"]
Total BPI Interference Score is [text name="variable_26" default=""]/70
DN4 Score[select name="variable_20" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10|form not filled"]
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.

CONSULTATIONS
[textarea name="variable_23" default=""]
Other Healthcare Professionals: [textarea name="variable_23" default=""]

PAST MEDICAL HISTORY
Surgical: [textarea name="variable_23" default=""]
[text name="variable_25" default=""]

Medical:[textarea name="variable_23" default=""]
[text name="variable_25" default=""]

FUNCTIONAL 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
[conditional field="gender" condition="(gender).is('Mrs')"] she [/conditional][conditional field="gender" condition="(gender).is('Mr.')"] he [/conditional] is currently [checkbox name="variable_36" value="single|married|widow|common law|divorced"] and is Presently living [text name="variable_37" default=""]. [conditional field="gender" condition="(gender).is('Mrs')"] she [/conditional][conditional field="gender" condition="(gender).is('Mr.')"] he [/conditional] 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|is 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
The patient’s mood is [text name="variable_25" default=""]. The patient’s anxiety score is [text name="variable_25" default=""] and depression score is [text name="variable_25" default=""]   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. 
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 HISTORY
Sexual function is reportedly [checkbox name="variable_b20" value="unimpaired|is adversely affected|is not a concern|impaired|both desire and physical ability are reduced by pain/medication"]. [conditional field="gender" condition="(gender).is('Mrs')"] she [/conditional][conditional field="gender" condition="(gender).is('Mr.')"] he [/conditional is [select name="variable_b22" value="unconcerned|concerned"] about this issue.[text name="variable_b23" default=""] 

SLEEP HISTORY
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.Worsening AM pain:[text name="variable_25" default=""] 
2.ETOH:[text name="variable_25" default=""]
3.Smoking:[text name="variable_25" default=""]
4.Prescription drugs: Off the street:[text name="variable_25" default=""] . Borrowed:[text name="variable_25" default=""] 	
5.Family psychiatric history:[text name="variable_25" default=""] 
6.Family History of substance abuse:[text name="variable_25" default=""] 
7.History of trauma - Emotional:[text name="variable_25" default=""] ; Physical;[text name="variable_25" default=""] ; Sexual;[text name="variable_25" default=""] 
8.Which recreational drugs has the patient used?[text name="variable_25" default=""] 
9.Has the patient ever received treatment for drug abuse?[text name="variable_25" default=""] 
10.UDS: [text name="variable_25" default=""]

Opiate Risk Tool: [text name="variable_25" default=""]

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"] Height: [text name="D6" default=""] BMI: [text name="D7" default=""] [conditional field="gender" condition="(gender).is('Mrs')"] female [/conditional][conditional field="gender" condition="(gender).is('Mr.')"]  [/conditional]

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=""]

[select name="OM1" value="|HEAD & FACE|NECK|UPPER BACK|LOWER BACK|SHOULDER|ELBOW|WRIST|HIP|KNEE|ANKLE & FOOT"] [conditional field="OM1" condition="(OM1).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 
[text name="variable_jk1" default="."] 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="OM1" condition="(OM1).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="OM1" condition="(OM1).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 tendinitis [select name="variable_172" value="was negative bilaterally| was positive over right shoulder| was positive over left shoulder|was positive bilaterally"]. 
supraspinatus impingement/partial tear test [select name="variable_173" value="was negative| was positive over right shoulder| was positive over left shoulder|was positive both shoulders"]. 
cross arm test for AC-joint arthritis was [select name="variable_174" value="negative| positive"] [text name="variable_b66" default="."]
[/conditional][conditional field="OM1" condition="(OM1).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="OM1" condition="(OM1).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="OM1” condition="(OM1).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"].[/conditional] 
[conditional field="OM1" condition="(OM1).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="OM1" condition="(OM1).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="."] [/conditional][conditional field="OM1" condition="(OM1).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"]
anterior drawer test [select value="negative|positive"]
posterior drawer test [select value="negative|POSITIVE"]
McMurray's test for meniscus check [select value="negative|positive"] [text name="variable_CC63" default="."][/conditional][conditional field="OM1" condition="(OM1).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="OM2" value="|HEAD & FACE|NECK|UPPER BACK|LOWER BACK|SHOULDER|ELBOW|WRIST|HIP|KNEE|ANKLE & FOOT"] [conditional field="OM2" condition="(OM2).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 
[text name="variable_jk1" default="."] 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="OM2" condition="(OM2).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="OM2" condition="(OM2).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 tendinitis [select name="variable_172" value="was negative bilaterally| was positive over right shoulder| was positive over left shoulder|was positive bilaterally"]. 
supraspinatus impingement/partial tear test [select name="variable_173" value="was negative| was positive over right shoulder| was positive over left shoulder|was positive both shoulders"]. 
cross arm test for AC-joint arthritis was [select name="variable_174" value="negative| positive"] [text name="variable_b66" default="."]
[/conditional][conditional field="OM2" condition="(OM2).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="OM2" condition="(OM2).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="OM2” condition="(OM2).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"].[/conditional] 
[conditional field="OM2" condition="(OM2).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="OM2" condition="(OM2).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="."] [/conditional][conditional field="OM2" condition="(OM2).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"]
anterior drawer test [select value="negative|positive"]
posterior drawer test [select value="negative|POSITIVE"]
McMurray's test for meniscus check [select value="negative|positive"] [text name="variable_CC63" default="."][/conditional][conditional field="OM2" condition="(OM2).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="OM3" value="|HEAD & FACE|NECK|UPPER BACK|LOWER BACK|SHOULDER|ELBOW|WRIST|HIP|KNEE|ANKLE & FOOT"] [conditional field="OM3" condition="(OM3).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 
[text name="variable_jk1" default="."] 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="OM3" condition="(OM3).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="OM3" condition="(OM3).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 tendinitis [select name="variable_172" value="was negative bilaterally| was positive over right shoulder| was positive over left shoulder|was positive bilaterally"]. 
supraspinatus impingement/partial tear test [select name="variable_173" value="was negative| was positive over right shoulder| was positive over left shoulder|was positive both shoulders"]. 
cross arm test for AC-joint arthritis was [select name="variable_174" value="negative| positive"] [text name="variable_b66" default="."]
[/conditional][conditional field="OM3" condition="(OM3).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="OM3" condition="(OM3).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="OM3” condition="(OM3).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"].[/conditional] 
[conditional field="OM3" condition="(OM3).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="OM3" condition="(OM3).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="."] [/conditional][conditional field="OM3" condition="(OM3).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"]
anterior drawer test [select value="negative|positive"]
posterior drawer test [select value="negative|POSITIVE"]
McMurray's test for meniscus check [select value="negative|positive"] [text name="variable_CC63" default="."][/conditional][conditional field="OM3" condition="(OM3).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="OM4" value="|HEAD & FACE|NECK|UPPER BACK|LOWER BACK|SHOULDER|ELBOW|WRIST|HIP|KNEE|ANKLE & FOOT"] [conditional field="OM4" condition="(OM4).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 
[text name="variable_jk1" default="."] 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="OM4" condition="(OM4).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="OM4" condition="(OM4).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 tendinitis [select name="variable_172" value="was negative bilaterally| was positive over right shoulder| was positive over left shoulder|was positive bilaterally"]. 
supraspinatus impingement/partial tear test [select name="variable_173" value="was negative| was positive over right shoulder| was positive over left shoulder|was positive both shoulders"]. 
cross arm test for AC-joint arthritis was [select name="variable_174" value="negative| positive"] [text name="variable_b66" default="."]
[/conditional][conditional field="OM4" condition="(OM4).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="OM4" condition="(OM4).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="OM4” condition="(OM4).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"].[/conditional] 
[conditional field="OM4" condition="(OM4).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="OM4" condition="(OM4).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="."] [/conditional][conditional field="OM4" condition="(OM4).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"]
anterior drawer test [select value="negative|positive"]
posterior drawer test [select value="negative|POSITIVE"]
McMurray's test for meniscus check [select value="negative|positive"] [text name="variable_CC63" default="."][/conditional][conditional field="OM4" condition="(OM4).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="OM5" value="|HEAD & FACE|NECK|UPPER BACK|LOWER BACK|SHOULDER|ELBOW|WRIST|HIP|KNEE|ANKLE & FOOT"] [conditional field="OM5" condition="(OM5).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 
[text name="variable_jk1" default="."] 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="OM5" condition="(OM5).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="OM5" condition="(OM5).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 tendinitis [select name="variable_172" value="was negative bilaterally| was positive over right shoulder| was positive over left shoulder|was positive bilaterally"]. 
supraspinatus impingement/partial tear test [select name="variable_173" value="was negative| was positive over right shoulder| was positive over left shoulder|was positive both shoulders"]. 
cross arm test for AC-joint arthritis was [select name="variable_174" value="negative| positive"] [text name="variable_b66" default="."]
[/conditional][conditional field="OM5" condition="(OM5).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="OM5" condition="(OM5).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="OM5” condition="(OM5).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"].[/conditional] 
[conditional field="OM5" condition="(OM5).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="OM5" condition="(OM5).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="."] [/conditional][conditional field="OM5" condition="(OM5).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"]
anterior drawer test [select value="negative|positive"]
posterior drawer test [select value="negative|POSITIVE"]
McMurray's test for meniscus check [select value="negative|positive"] [text name="variable_CC63" default="."][/conditional][conditional field="OM5" condition="(OM5).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="OM6" value="|HEAD & FACE|NECK|UPPER BACK|LOWER BACK|SHOULDER|ELBOW|WRIST|HIP|KNEE|ANKLE & FOOT"] [conditional field="OM6" condition="(OM6).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 
[text name="variable_jk1" default="."] 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="OM6" condition="(OM6).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="OM6" condition="(OM6).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 tendinitis [select name="variable_172" value="was negative bilaterally| was positive over right shoulder| was positive over left shoulder|was positive bilaterally"]. 
supraspinatus impingement/partial tear test [select name="variable_173" value="was negative| was positive over right shoulder| was positive over left shoulder|was positive both shoulders"]. 
cross arm test for AC-joint arthritis was [select name="variable_174" value="negative| positive"] [text name="variable_b66" default="."]
[/conditional][conditional field="OM6" condition="(OM6).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="OM6" condition="(OM6).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="OM6” condition="(OM6).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"].[/conditional] 
[conditional field="OM6" condition="(OM6).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="OM6" condition="(OM6).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="."] [/conditional][conditional field="OM6" condition="(OM6).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"]
anterior drawer test [select value="negative|positive"]
posterior drawer test [select value="negative|POSITIVE"]
McMurray's test for meniscus check [select value="negative|positive"] [text name="variable_CC63" default="."][/conditional][conditional field="OM6" condition="(OM6).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="OM8" value="|HEAD & FACE|NECK|UPPER BACK|LOWER BACK|SHOULDER|ELBOW|WRIST|HIP|KNEE|ANKLE & FOOT"] [conditional field="OM8" condition="(OM8).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 
[text name="variable_jk1" default="."] 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="OM8" condition="(OM8).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="OM8" condition="(OM8).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 tendinitis [select name="variable_172" value="was negative bilaterally| was positive over right shoulder| was positive over left shoulder|was positive bilaterally"]. 
supraspinatus impingement/partial tear test [select name="variable_173" value="was negative| was positive over right shoulder| was positive over left shoulder|was positive both shoulders"]. 
cross arm test for AC-joint arthritis was [select name="variable_174" value="negative| positive"] [text name="variable_b66" default="."]
[/conditional][conditional field="OM8" condition="(OM8).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="OM8" condition="(OM8).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="OM8” condition="(OM8).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"].[/conditional] 
[conditional field="OM8" condition="(OM8).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="OM8" condition="(OM8).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="."] [/conditional][conditional field="OM8" condition="(OM8).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"]
anterior drawer test [select value="negative|positive"]
posterior drawer test [select value="negative|POSITIVE"]
McMurray's test for meniscus check [select value="negative|positive"] [text name="variable_CC63" default="."][/conditional][conditional field="OM8" condition="(OM8).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="OM7" value="|HEAD & FACE|NECK|UPPER BACK|LOWER BACK|SHOULDER|ELBOW|WRIST|HIP|KNEE|ANKLE & FOOT"] [conditional field="OM7" condition="(OM7).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 
[text name="variable_jk1" default="."] 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="OM7" condition="(OM7).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="OM7" condition="(OM7).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 tendinitis [select name="variable_172" value="was negative bilaterally| was positive over right shoulder| was positive over left shoulder|was positive bilaterally"]. 
supraspinatus impingement/partial tear test [select name="variable_173" value="was negative| was positive over right shoulder| was positive over left shoulder|was positive both shoulders"]. 
cross arm test for AC-joint arthritis was [select name="variable_174" value="negative| positive"] [text name="variable_b66" default="."]
[/conditional][conditional field="OM7" condition="(OM7).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="OM7" condition="(OM7).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="OM7” condition="(OM7).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"].[/conditional] 
[conditional field="OM7" condition="(OM7).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="OM7" condition="(OM7).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="."] [/conditional][conditional field="OM7" condition="(OM7).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"]
anterior drawer test [select value="negative|positive"]
posterior drawer test [select value="negative|POSITIVE"]
McMurray's test for meniscus check [select value="negative|positive"] [text name="variable_CC63" default="."][/conditional][conditional field="OM7" condition="(OM7).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]
Yours truly,
Peter Emelike, dictating for
_____, MD
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

.
With respect to the patient’s complaint of back pain, the patient reports
bowel or bladder dysfunction. There is
saddle anaesthesia, weakness, or radiation reported.
thoracic pain, fever, weight loss, night sweats, immunosuppression or history of carcinoma. The patient
overt trauma,
I.V. drug use,
chronic steroid use
substantive night pain.

With respect to the patient’s complaint of neck pain, the patient reports
paresthesia, weakness or radiation.
thoracic pain,
fever,
weight loss,
night sweats,
immunosuppression or history of carcinoma. The patient
overt trauma,
I.V drug use,
chronic steroid use
substantive night pain.

The patient’s headache is
associated with nausea,
vomiting,
photophobia,
phonophobia. There are
reported visual changes or aura.
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."

The patient has
used physiotherapy,
. The patient takes
medication. The patient does
smoke marijuana.

On an NRS scale the pain rating is at its worst, at best. on average it is and currently the pain is
Total BPI Interference Score is /70
DN4 Score
Fibromyalgia Rapid Screening Tool: , for diagnosis of fibromyalgia.

CONSULTATIONS

Other Healthcare Professionals:

PAST MEDICAL HISTORY
Surgical:


Medical:


FUNCTIONAL 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
is currently and is Presently living . has children, .The patient’s highest level of education completed is

PSYCHOLOGICAL STATUS AND RELATED MATTERS
The patient’s mood is . The patient’s anxiety score is and depression score is There history of suicidal ideation and the patient previous suicide attempts. The current suicide risk is . The patient a psychiatrist.
Smoking:
Alcohol:
Illicit drug:

SEXUAL HISTORY
Sexual function is reportedly . he [/conditional is about this issue.

SLEEP HISTORY
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.Worsening AM pain:
2.ETOH:
3.Smoking:
4.Prescription drugs: Off the street: . Borrowed:
5.Family psychiatric history:
6.Family History of substance abuse:
7.History of trauma - Emotional: ; Physical; ; Sexual;
8.Which recreational drugs has the patient used?
9.Has the patient ever received treatment for drug abuse?
10.UDS:

Opiate Risk Tool:

PHYSICAL EXAMINATION
Age: BP: HR: Weight: Height: BMI:

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.

























Yours truly,
Peter Emelike, dictating for
_____, MD

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.5, 2049 form elements, 421 boilerplate words, 898 text boxes, 35 text areas, 1 dates, 88 checkboxes, 855 drop downs, 172 conditionals, 2570 total clicks
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