Carlotta A Russe V5 PC
Interview
Chief Complaint
How can I help you today?
Do you have any other symptoms or concerns we should discuss?
Have you had any trauma to your back?
Old carts for HPI
What are the events surrounding the start of your back pain?
What are the events surrounding the start of the pain in your leg(s)?
When did the pain in your back start?
Does the pain in your back radiate someplace else? Where?
Where more precisely is the pain in your leg(s)?
Where more precisely is the pain in your back?
Does the pain in your back come and go?
What does the pain in your back feel like?
Do you have pain when lifting?
Does anything make the pain in your back better or worse?
How severe (1-10 Scale) is the pain in your back?
PMH, FH, SH as Needed
Any new or recent change in medications?
Are you taking any over the counter or herbal medications?
Do you have any allergies?
Review of Systems (ROS)
Do you have problems with heat or cold intolerance, increased thirst, increased sweating,
frequent urination, or change in appetite?
Do you have problems with dizziness, fainting, spinning room, seizures, weakness, numbness,
tingling, or tremor?
Do you have problems with fatigue, difficulty sleeping, unintentional weight loss or gain, fevers,
or night sweats?
Interview
Chief Complaint
How can I help you today?
Do you have any other symptoms or concerns we should discuss?
Have you had any trauma to your back?
Old carts for HPI
What are the events surrounding the start of your back pain?
What are the events surrounding the start of the pain in your leg(s)?
When did the pain in your back start?
Does the pain in your back radiate someplace else? Where?
Where more precisely is the pain in your leg(s)?
Where more precisely is the pain in your back?
Does the pain in your back come and go?
What does the pain in your back feel like?
Do you have pain when lifting?
Does anything make the pain in your back better or worse?
How severe (1-10 Scale) is the pain in your back?
PMH, FH, SH as Needed
Any new or recent change in medications?
Are you taking any over the counter or herbal medications?
Do you have any allergies?
Review of Systems (ROS)
Do you have problems with heat or cold intolerance, increased thirst, increased sweating,
frequent urination, or change in appetite?
Do you have problems with dizziness, fainting, spinning room, seizures, weakness, numbness,
tingling, or tremor?
Do you have problems with fatigue, difficulty sleeping, unintentional weight loss or gain, fevers,
or night sweats?
