Neck/Upper Back Pain/Injury symptom checklist evaluation

Neck/Upper Back Pain/Injury 
Onset [text] prior to evaluation
Onset while:  [text]
Injury at: [text]

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

Relieved with [text]
Worse with [text]
[select value="no|YES"] <--  worse with cough or deep breathing

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