HISTORY AND EXAMINATION
Name____________________________ M / F Initial visit date_____________
Date of birth______________
Oswestry Disability Index Score today__________ Pain today (at this moment)___________
Chief Complaint_______________________________________________________________
Region
Quality
Palliative factors
Provocative factors
Radiation of symptoms NO/YES___________________________________
Radicular symptoms NO / YES___________________________________
Temporal: constant / comes and goes date onset this episode_________________
Mechanism of onset: NKPE / _____________________________________
Trauma: NO / YES ___________________________________________
RED flags: none present / hx CA/ recent infection/ fever/ chills/ night sweats/ IV drug use/
unexplained weight loss/ significant trauma/ minor trauma with steroid use or osteopenia/
failure 4 wks conservative care/ perineal numbness/ bowel or bladder control issues/
immunosuppression/ Other:
Past medical history/system review/ medication usage currently
Surgical history/serious illness:
Allergies _________________________________________________ / NKDA
Prior treatment for this episode NO / YES
What____________________ When____________________ Response_________________________
Prior diagnostic testing for this episode NO / YES
What___________ When_____________ Where______________ Requested results______________
Prior similar episodes NO/YES
When____________ Treatment_________________ Response________________________
Diagnostic testing for prior episodes NO / YES
What__________ When___________ Where_______________ Requested results_____________
Doctor initials__________
NAME_______________________________ Date_____________ Ht: Wt:
DTRs R Achilles 0/1/2/2+/3 R Patella 0/1/2/2+/>3 BP :
L Achilles 0/1/2/2+/3 L Patella 0/1/2/2+/>3
RED FLAGS : NONE/progressive neuro deficit, perineal numbness
Muscles
R Quad 0/1/2/3/4/5 R Pl flexion 0/1/2/3/4/5 R EHL 0/1/2/3/4/5 R Tib Ant 0/1/2/3/4/5
L Quad 0/1/2/3/4/5 L Pl flexion 0/1/2/3/4/5 L EHL 0/1/2/3/4/5 L Tib Ant 0/1/2/3/4/5
SLR WNL bilaterally/ positive at _______degrees on R/L for _____________________________
Pulses Popliteal WNL bilaterally / decreased R/L / absent R/L
Post Tibial WNL bilaterally / decreased R/L / absent R/L
Dorsal Pedal WNL bilaterally / decreased R/L / absent R/L
Sensory Pinwheel WNL bilaterally L.E./ hyper/hypo at dermatome__________ on R/L
Light touch WNL bilaterally L.E./ hyper/hypo at dermatome__________ on R/L
(the items below are not required by NCQA but serve to increase examination data)
Observation
Range of Motion Directional Preference:
Left hip WNL/____________________________________
Right hip WNL/____________________________________
Palpation Tender( I – IV) Muscle tone Alignment
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T12 – L1 |
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L1 – L2 |
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L2 – L3 |
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L3 – L4 |
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L4 – L5 |
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L5 – S1 |
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SI |
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Orthopedic tests
Systems
Doctor initials__________
NAME_________________________________________ Date_________________________
Employment status
Occupation:
Job duties (related to spine):
Full time employment Part time employment Usual hours per week___________
Working/Working with restrictions/ Not working-partial disability /Not working-total
Disability dates for this episode:
Work restrictions:
Dates for work restrictions:
Dates of disability:
Expected return to work date:
W.C. or litigation involved: NO / YES ____________________________________
Mental Health Assessment NO/YES
Imaging: Not ordered by this office / ordered by this office(see below)
X-Ray region____________ date___________ rationale____________________
MRI region____________ date___________ rationale____________________
CT region____________ date___________ rationale_____________________
Non Smoker_____
Smoker______ _____packs for ______years
Advice to quit smoking given to patient: NO / YES
and
Referral to smoking cessation program: NO / YES program____________________
Advice given to resume normal activities early in course of condition: NO / YES
Advice given to patient to avoid bed rest for more than 4 days: NO / YES
Advice on exercise (includes stretch/strengthen/aerobic)
Supervised exercise program: NO / YES date referred_______________
Or
Home exercise advice: NO / YES date given_______ follow up date________
Patient Education information given to patient YES / NO
Referral not indicated ______
Referral To__________ On________ For_____________ Why___________________________________
Patient satisfaction assessed YES / NO
Reassessment within 4 weeks:
Date______________ Pain________________
Disability Index _____________________