Chief Complaint

Prior Level of Function Independent Modified Independence Moderate Assistance Minimal Assistance Moderate Assistance Maximal Assistance Total Assistance Supervision Some Assistance Dependent

History of Fall

When It Is Worse : (0-10) 0 - No Pain 1 - Mild Pain 2 - Mild Pain 3 - Moderate Pain 4 - Moderate Pain 5 - Moderate Pain 6 - Severe Pain 7 - Severe Pain 8 - Severe Pain 9 - Severe Pain 10 - Severe Pain

When It Is Best : (0-10) 0 - No Pain 1 - Mild Pain 2 - Mild Pain 3 - Moderate Pain 4 - Moderate Pain 5 - Moderate Pain 6 - Severe Pain 7 - Severe Pain 8 - Severe Pain 9 - Severe Pain 10 - Severe Pain

What Is It Currently? : (0-10) 0 - No Pain 1 - Mild Pain 2 - Mild Pain 3 - Moderate Pain 4 - Moderate Pain 5 - Moderate Pain 6 - Severe Pain 7 - Severe Pain 8 - Severe Pain 9 - Severe Pain 10 - Severe Pain

Shoulder (left) Arm (left) Elbow (left) Forearm (left) Wrist (left) Hand (left) Finger Little (left) Finger Ring (left) Finger Middle (left) Finger Index (left) Finger Thumb (left) Hip (left) Leg (left) Knee (left) Ankle (left) Foot (left) Toe (left)

Head Neck Chest Abdomen Back Private (male) Private (female)

Shoulder (right) Arm (right) Elbow (right) Forearm (right) Wrist (right) Hand (right) Finger Little (right) Finger Ring (right) Finger Middle (right) Finger Index (right) Finger Thumb (right) Hip (right) Leg (right) Knee (right) Ankle (right) Foot (right) Toe (right)

Please specify the other body part.

Allgeries Anemia Angina Arrhythmia Asthma/Emphysema Back or Neck Injury Bleeding Disorder Cancer Chest Pain Chronic Bronchitis Circulatory Problems

COPD Depression/Anxiety Diabetes Dizzy Spells/Vertigo Epilepsy/Seizures Fainting Spells Headaches Hearth Attack Hepatitis A, B or C High Blood Pressure Incontinence

Lymphedema Osteoporosis Angina Neuropathy Parkinson's Disease Pregnancy Rheumatoid/Osteo-Arthritis Stroke/TIA's Total Joint Replacement Tuberculosis Other

Bipolar Hip Surgery Craniotomy CABG Femoral Popliteal Bypass Gastric Bypass Greenfield Filter Incision/Drainage Laminectomy

Mastectomy/Reconstruction Open Reduction Int Fixatn Rotator Cuff Repair Spinal Spinal Fusion Total Hip Replacement Total Knee Replacement Other