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CHIEF COMPLAINT
HPI
SYMPTOM LIST
•Unpleasant sensations in their calves, thighs, feet or arms
•Deep-seated
•Creeping
•Crawling
•Jittery
•Tingling
•Burning
•Aching
•Numbness
•Starts during inactivity
•Relief by movement
•Worsening of symptoms in the evening
•Nighttime leg twitching
SEVERITY
•Mild
•Moderate
•Severe
•Normal
•Increased
•Decreased
•Stable
•No significant change from prior visit
ONSET
•Sudden
•Gradual
DURATION
•Recent
•Few days
•Many days
•Few weeks
•Many weeks
•Few months
•Many months
•Few years
•Many years
FREQUENCY
•Intermittent
•Continuous
AGGRAVATED BY
RELIEVED BY
NOTES
HISTORY (PMFSH)
PAST HISTORY
•Diabetes
•Peripheral neuritis
•Hypertension
ALLERGY-Drugs
-Environment
FAMILY HISTORY
•Diabetes
•Hypertension
SOCIAL HISTORY
•Habits
o Tobacco
o Alcohol
o Drugs
•Occupation
ROS
PHYSICAL EXAMINATION
TESTS TO BE ORDERED
•Hb%
•Serum electrolytes
•Serum calcium
•Urinalysis
MEDICATION
Pramipexole
Carbidopa
Levodopa
Codeine
Acetaminophen
Clonazepam
Eszopiclone
Ramelteon
Temazepam
Zaleplon
Zolpidem
Gabapentin
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