Schema

Diagnosis

Do you have a formal diagnosis from your physician?

Referring physician

Who is the physician who referred you to physical therapy?

Biographical data

Can you tell me your name and DOB? how do you identify in terms of gender, and which pronouns do you prefer I use when addressing you?

Chief complaint

Can you tell me about the reason or reasons you came to therapy today?

Location

Do you have this pain right now?

Where is it currently located?

Show me exactly where your pain is located

Where did the pain begin?

Do you have pain or symptoms anywhere else?

Has the location of the pain changed?

Where has the pain been in the past?

Character or quality

What does it feel like?

Has the pain changed in quality since it first began?

Quantity or severity

On a scale of 0-10, with 0 being no pain at all and 10 being the worst pain you could imagine, how would you rate your pain?

Has the pain changed in intensity since it first began?

What is the degree of pain and/or disability?

How much is the problem impacting your day-to-day life?

Is the pain getting worse, better, or staying the same?

Timing (onset, duration, frequency)

When did the pain begin?

How long do symptoms last?

Is there a time of day pattern?

Are your symptoms worse in the morning or evening?

Are your symptoms worse at night? While sleeping?

Has the pain changed in duration since it first began?

How does your pain/symptoms change with time?

Have you ever experienced anything like this before?

Are your episodes occurring more or less frequently?

Setting

Where are you when your symptoms are at their worst?

Where are you when your symptoms are at their best?

Aggravating or relieving factors

What brings your pain on?

What makes the pain worse? Better?

What activities make your pain worse? Better?

How does rest affect the pain/symptoms?

How has the problem affected your daily life?

Associated symptoms

Have you noticed any other symptoms, or is there anything else that's also giving you pain?

Client's perception of the symptom

Can you tell me how this pain has affected you and what your experience has been like dealing with it?

What cant you do today that you were able to before the injury?

Mechanism of injury

Pattern of Injury and/or onset: Can you think of anything that may have caused or might have led to this pain?

Chronology and progression: Can you describe how your pain has progressed over these past months?

Diagnostic tests

Have you had any diagnostic tests performed for your condition? This could include imaging studies such as X-rays, MRI scans, or CT scans, as well as laboratory tests or other procedures.

List of medications w/ dosage and prescribing physician(s)

Can you please provide me with a list of all the medications you are currently taking?

Include the dosage of each medication and the name(s) of the physician(s) who prescribed them.

Allergies

Do you have any known allergies?

Specifically, are there any medications or substances that you are allergic to?

Current and past medical history

Can you provide some information about your current health status?

Have you experienced any significant medical events in the past?

Do you have any ongoing medical conditions or take any medications?

ROS/Red Flags

Health habits/health maintenance practices

How often do you exercise, and what kind of physical activity do you engage in?

Past surgical history

Have you had any surgeries in the past? If so, when and what was the reason?

Family history

Are there any significant medical conditions that run in your family?

Has anyone in your family experienced similar symptoms or conditions?

Risk/predisposing factor assessment

Are there any factors in your lifestyle or environment that may contribute to your condition?

Related personal history

Can you describe your occupation and any physical demands it may have?

What are your hobbies and recreational activities?

Do you have any difficulty with daily tasks or activities?

Assistive devices

Exercise

Sleep habits/social

Stairs

Special screening considerations

Have you ever experienced neglect, abuse, or violence?

Have you had any mental health concerns or been diagnosed with a mental health disorder?

Prior history of physical therapy

Have you received physical therapy in the past?

If so, what was the reason for your previous therapy, what interventions were used, and what were the outcomes?

Patient/client goals

What are your goals for physical therapy?