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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