Initial Visit - Description of Present Illness

This section includes much of the same information included under History. If the same information has already been documented in the previous section, it is appropriate to write "same as above" or "see previous section."

For examples of each of these points, refer to the History section:

• Mechanism of trauma
• Quality and character of symptoms/problems
• Onset, duration, intensity, frequency, location, radiation of symptoms
• Aggravating or relieving factors
• Prior interventions, treatments, medications, secondary complaints
• Symptoms prompting visit for treatment