SoCal Neurosurgery

📝 Edit the note below. Sign locks it as the official note. Click 🤖 AI note (top-right) any time to have AI refine what you've written — optional.

Accident

Date of Injury:

Position in vehicle: Driver Passenger (front) Passenger (rear)

Restrained: Yes No

Loss of consciousness: Yes No

Airbags deployed: Yes No

Emergency room visit: Yes No

Urgent care visit: Yes No

Chief Complaint

Mark neck / mid-back / low-back / headache locations on the Pain Diagram below (severity 1–10). Use "+ Add other complaint" for anything else.

Pain Diagram

Click a region to mark pain (you'll be prompted for severity 1–10). Click again to clear.

Numbness / Tingling Diagram

Click a region to mark numbness or tingling. Click again to clear.

Current Pain Medications

None

Other:

Type of Treatment

Chiropractic therapy: Yes No

Acupuncture: Yes No

Physical Therapy: Yes No

Injections — C spine: Yes No Sessions:

Injections — L spine: Yes No Sessions:

Other treatment:

Past Medical History

None

Other:

Past Surgical History

None Yes (select below)

Cardiothoracic / vascular: CABG Cardiac stent Pacemaker Vascular

GU / GYN: Hysterectomy C-section Prostate Kidney

Head & neck / other: Craniotomy Tonsillectomy Thyroid Eye

Other / details:

Social

Smoking: Non-Smoker Vapes Smokes Cigs/packs per day:

Alcohol: None Occasional Regularly Drinks/day:

Allergies: None Yes

Other:

Physical Exam

Height: Weight: BP: Pulse:

Other / Plan

Other comments:

Return to clinic in 4–6 weeks Discharged from care, return if symptoms relapse

Attach files for print (optional, images and PDFs):

Appointments

Patients

Chart Notes

Tasks

Billing

Neurosurgery - Initial Consultation

Pain Diagram

Numbness / Tingling Diagram

Current Pain Medications

Type of Treatment

Past Medical History

Past Surgical History

Social

Physical Exam

Cervical

Thoracic

Lumbar

Neurological

Recommendations — C spine

Recommendations — T spine

Recommendations — L spine

Recommendations — Headache management

Other / Plan