Hess Orthopaedic Center and Sports Medicine, PLC

History of Present Illness

Today's Date:
Patient Name:
Date of Birth:
Age:
Primary Care Physician:
Referring Physician:
Height:
Weight:
Right HandedLeft Handed

Chief Complaint: What is the reason for your visit today? Please include right, left, and bilateral (if applicable)

Duration: How long have you had pain/symptoms?

Was there an injury? YesNo
If Yes, date of injury:
Describe injury:
Job related? YesNo
Auto accident? YesNo
If Yes, State:

Location: Where is the location of pain

Severity: What is your pain level? Please choose:

123456

Quality: What is the quality of your pain?

DulSharpElectricalBurningPins and NeedlesOther

Timing/Context: How long do symptoms last? When do symptoms occur (time of day, after activities, etc.)?

Modifying factors: What makes the pain feel better? What makes the pain feel worse?

Associated signs/symptoms: Is there any swelling, redness, etc?

List any prior treatments and when/where performed (examples: surgery, braces, physical therapy, injections, medications):

Have you had any of the following studies previously? Mark if applicable and list when/where performed:

MRICT ScanEMG needle studyBone scanUltrasoundBlood workOther (explain)
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