CHIEF COMPLAINT HPI FORM

Patient Name:_______________________

Date:_____________

CHIEF COMPLAINT HPI FORM

CHIEF COMPLAINT:
Body Area Involved: Condition Type:

Pain

Numbness

Stiffness

Weakness
Upper Extremity Exacerbation Lower Extremity Chronic

Head/Neck New

Spine/Ribs/Pelvis Recurring

1.) Does anyone else in the family have this same or similar problem? (Check family history.)

MECHANISM OF ONSET:
2.) Before you began to suffer with this problem, was there an earlier accident, injury or condition that may or may not have been directly related to this problem? (Example: fall, auto injury, sports trauma, repetitive motion on the job.)

Auto Work Other No Injury

Restrained Overexertion Etiology Unk

Unrestrained Lifting Slip/Fall

Driver Repetitive Motion Overexertion

Passenger Fall Recreation

Pedestrian See Accident Hx Form See Accident Hx Form Slept Wrong Other________________

LOCATION: SYMPTOMS: When this problem is at its worst, can you explain in your words how exactly it feels? Does it radiate?

Right/Left/Bilateral

QUALITY:
Burning Shooting Diffuse Stabbing Dull/Aching Tingling Localized Radiating Sharp Other

SEVERITY:
Minimal Mild Mild/Moderate Moderate Moderate/Severe Severe

On a scale of 0-10, where 10 is the worst pain you have ever felt, can you rate that pain?
Level of Impairment Due to Symptoms (Resting): 0 1 2 3 4 5 6 7 8 9 10

Level of Impairment Due to Symptoms (With Activity): 0 1 2 3 4 5 6 7 8 9 10

How does that make you feel?

DURATION: How long have you been suffering from this problem? (Major Complaint)
Sx Started: Injury Date: Sx Worsened: Sx Last Episode: Sx Last Occurred: Accident Occurred:

TIMING:
Worse AM Worse PM Worse w/ Activity Intermittent Constant Worse at Night How often do you find yourself suffering from this problem? How long does the problem last? (Get all the details of timing)

CONTEXT:
Better When: Hot Cold Worse When: Hot Cold Damp

ASSOCIATED SIGNS SYMPTOMS:

Headache Stiffness Weakness - Location Swelling Irritability Spasm Other Numbness Radiation - Location Dizziness Nausea Fatigue

Patient Name ________________________ HEADACHE Location: Occipital Frontal Quality: Dull Sharp Types: Hat Band Cluster MODIFYING FACTORS:

Date _____________ Temporal Throbbing Migraine Pareital Stabbing Tension Sinus Aura

No Aura

Since the time you began suffering from this problem, what if anything have you tried so far that permanently helped you? (Ex: Ice, Heat, Rest, OTC Meds, Prescriptions, Physical Therapy) How much? How often? Symptoms Better With: Activity OTC Meds Twisting Symptoms Worse With: Bending Rx Meds Walking Cold Rest Heat Stretching Massage Sitting Movement Standing

As Noted in Social History

Has anything that you have done, thus far, fixed your problem? YES or NO When this problem is at its worst, does it make you feel older than you are? In other words, does this condition the way you have described it so far seem to you to be normal for your actual age? YES or NO How old? Have you become discouraged/frustrated about this problem? (from above) (IF NO) So what would you say it was if not discouraged?

SOCIAL HISTORY QUESTIONNAIRE

Give me an example of a day when your problem was at its worst, how did it ruin things for you? How does this problem affect your family?

DAILY ACTIVITIES:
Care - Family Member Carrying Groceries Change Positions Sit to Stand Climbing Stairs Pet Care Driving Extended Computer Use Household Chores Lifting Children Reading/Concentration Self Care - Bathing Self Care - Dressing Self Care - Shaving Sexual Activities Sleep Static Sitting Static Standing Yardwork Walking

Effects of Current Condition on Performance

No Effect No Effect No Effect No Effect No Effect No Effect No Effect No Effect No Effect No Effect No Effect No Effect No Effect No Effect No Effect No Effect No Effect No Effect Painful (can do) Painful (can do) Painful (can do) Painful (can do) Painful (can do) Painful (can do) Painful (can do) Painful (can do) Painful (can do) Painful (can do) Painful (can do) Painful (can do) Painful (can do) Painful (can do) Painful (can do) Painful (can do) Painful (can do) Painful (can do) Panfull (limits) Panfull (limits) Panfull (limits) Panfull (limits) Panfull (limits) Panfull (limits) Panfull (limits) Panfull (limits) Panfull (limits) Panfull (limits) Panfull (limits) Panfull (limits) Panfull (limits) Panfull (limits) Panfull (limits) Panfull (limits) Panfull (limits) Panfull (limits) Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform

Patient Name ________________________

Date _____________

EMPLOYMENT:
Occupation: Work Hours Per Day: Job Classification: Sed (<5 lbs) Light (5-20 lbs) Moderate (20-50 lbs) Heavy (>50 lbs) Lifting Frequency: Constant (66-100% of day) Frequent (33-66% of day) Occasional (0-33% of day) Lifting Postures: Torso Knee Arm Shoulder High Near Off Posture Work Activity Postures: Sitting: Hours per day Standing: Hours per day Walking: Hours per day Bending Hours per day Climbing: Hours per day Pushing: Hours per day Pulling: Twisting: Hours per day Hours per day Phone: Assembly: No Effect Hours per day Hours per day Painful (can do) Machinery: Grasping: Painful(limits) Hours per day Hours per day Unable to Perform Kneeling: Hours per day Reaching: Hours per day

Repetitive Activities: Computer: Hours per day Hand Tools: Hours per day Conditions Effect on Job Performance:

RECREATIONAL ACTIVITY:
No Effect No Effect No Effect No Effect No Effect Painful (can do) Painful (can do) Painful (can do) Painful (can do) Painful (can do) Painful (limits) Painful (limits) Painful (limits) Painful (limits) Painful (limits) Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform

What activities does this problem prevent you from doing, either partially or totally, that you would really like to be doing again?

How does this problem prevent you from doing that? This problem you described has been going on for years/months. How do you see it in the future if you dont make the commitment to improve the condition? (above B-W-S)

So, taking into consideration what we have discussed here so far, do you see that you would need to change something you are doing in order for your (condition above) to improve? YES or NO

On a scale of 1 to 10, ten being the highest, rate your commitment to getting rid of the problem?

Concerns that could interfere with your commitment? (Time, Transportation, Other) Specify:

Doctor Signature:

Date: