The purpose of the history (Table 6-1) is to:
Develop a working relationship and establish lines of communication with the patient.
Elicit reports of potentially dangerous symptoms, or red flags, that require an immediate medical referral (Table 6-2).1
Determine the chief complaint, its mechanism of injury, its severity, and its impact on the patient's function.
Ascertain the specific location and nature of the symptoms.
Determine the irritability of the symptoms.
Establish a baseline of measurements.
Elicit information on the history and past history of the current condition.
Gather information about the patient's past general medical and surgical history, which can afford the clinician some insight as to the impact the information may have on the patient's tolerance or response to the planned intervention.
Determine the goals and expectations of the patient from the physical therapy intervention, and the functional demands of a specific vocational or avocational activity to which the patient is planning to return.
Table 6-1. Contents of the History |Favorite Table|Download (.pdf)
Table 6-1. Contents of the History
HISTORY OF CURRENT CONDITION
Did the symptoms begin slowly or was trauma involved?
How long has the patient had the presenting symptoms?
Where are the symptoms located?
How does the patient describe the symptoms?
PAST HISTORY OF CURRENT CONDITION
Has the patient had a similar injury in the past?
Was it treated or did it resolve on its own? If it was treated, how was it treated and did intervention help?
How long did the most recent episode last?
PAST MEDICAL/SURGERY HISTORY
How is the patient's general health?
What pertinent surgeries has the patient had?
Does the patient have any allergies?
MEDICATIONS PATIENT IS PRESENTLY TAKING, OTHER TESTS AND MEASURES
Has the patient had any imaging studies?
Has the patient had an EMG test, or a nerve conduction velocity test, which would suggest compromise to muscle tissue and/or neurologic system?
SOCIAL HABITS (PAST AND PRESENT)
Does the patient smoke? If so, how many packs per day?
Does the patient drink alcohol? If so, how often and how much?
Is the patient active or sedentary?
Is the patient married, living with a partner, single, divorced, widowed?
Is the patient a parent or single parent?
Is there a family history of the present condition?
GROWTH AND DEVELOPMENT
Is the patient right- or left-handed?
Were there any congenital problems?
What type of home does the patient live in with reference to accessibility?
Is there any support at home?
Does the patient use any extra pillows or special chairs to sleep?
What does the patient do for work?
How long has he or she worked there?
What does the job entail in terms of physical requirements?
How does the present condition affect the patient at work?
What level of education did the patient achieve?
FUNCTIONAL STATUS/ACTIVITY LEVEL
How does the present condition affect the patient's ...