This document provides guidance on effective history taking in physiotherapy. It discusses: - The importance of history taking for diagnosis, disease understanding, and physical exam focus. Trust and active listening are keys. - General guidelines for history taking, including gaining patient confidence, using simple language, and asking open, closed, or leading questions. - Elements to cover in the history such as preliminary data, chief complaint, present and past history, social history, and family history. - Challenges such as sensitive topics, anxious patients, language barriers, and avoiding common pitfalls like disrespecting culture or using confusing terminology. The overall message is that history taking is essential for physiotherapy, and

1. HISTORY TAKING IN
PHYSIOTHERAPY
Shrikant S. Sant.
1st yr. M.P.Th.
Community Physiotherapy

2. The Value of History Taking
 Some diseases are diagnosed only by history
e.g. angina, epilepsy, migraine, psychotropic
diseases
 Helping knowing the diseased system
 Helping differential diagnosis
 Evaluating the severity of the disease

3.  Directs the focus of the Physical Exam
 Often the basis for the differential diagnosis
 Keys
 Trust
 Right Questions
 Interpreting the responses
 Knowing what to do next
 Care begins simultaneously.

4. General guidelines
 You are like detective do not be fooled
by the patient
 Gain confidence of patient and melt the ice
 Patient is a living object: culture, emotion… etc
 Let patient express himself by his own words, be
aware of:
 Lack of accuracy
 Historian patients ?Talkative
 Exaggeration of symptoms
 Aggression and annoyed
 Worse patients are people who have medical
knowledge…. Misleading the diagnosis

5.  Eye contact & Position at eye level
 Appropriate distance & position
 Safety
 Respect
 Personal Zone
 Use simple language to be understood
 The questions are either:
 Neutral: e.g. “tell me about what you
have”
 Simple direct questions: “answered by yes
or no”
 Leading questions: “pain before or after
meal”.

6. Elements of the
Comprehensive History
 Tips for effective history-taking
 Open-ended questions
 “What seems to be bothering you today?”
 Closed-ended questions
 “Is your chest pain sharp or dull?”
 Multiple Choice Questions
 LISTEN ACTIVELY!!!
 ACT as if you are listening
 Repeat patient’s statements
 Clarify if needed
 Take notes
 Display your concern
 Confront with caution

7. Structure of History
 Preliminary data:
 Age, sex, ….
 Chief complain: Presenting symptoms
 Present history: detailed description of the illness
 Review other systems
 Past history
 Personal history: detailed occupation residency..
Etc
 Family history: similar disease in the family
 Social history smoking, alcohol, drugs…
 Summary

8. Preliminary Data
 Name:
 Age: children diseases, adult, genetic,
autoimmune diseases
 Sex: hemophilia, CAD
 Marital status:
 Occupation: chemicals, mental stress
 Residence: unusual infection
 Traveling
 Nationality
 Religion

9. Chief complain
 Make it simple, in patient own words
 At the time of examination
 Specify the duration
 No medical terms

10. Present History
 Detailed description of illness
 Analyze the complain in relation to other c/o
 Chronological sequence
 Consider the following:
 Onset: sudden (hrs), acute (1-3 days), sub acute (1-
2W), gradual and insidious.. (overtime)
 Course (progressive, retrogressive, stationary,
fluctuant)
 Duration: for how long
 Severity (fro 1-10 score)

11. Past History
 Previous illness, operations, infection… in
chronological order
 Surgery
 Illness: childhood, parasitic, hepatitis, rheumatic
fever, venereal diseases … etc
 Trauma: fracture, hemorrhage… etc
 Traveling and residence abroad (immunization)
 Blood transfusion
 Pregnancy and prenatal history (German measles)

13. Drug therapy

14. Personal History
 Residence,
 Occupation: occupational hazards
 Dust: pneumoconiosis
 Chemicals: metals, insecticidal
 Physical factors: ionizing radiation, high
temperature
 Infection: cattle,
 Degree of effort
 Education
 Hobbies

15.  Habits:
 Tea, coffee, alcohol, tobacco, drugs:
 Ask about: duration and amount
 Hours of sleep and exercise
 Marital history: sex history and pregnancy
history

16. Social History
 Economic status
 Housing, malnutrition
 Social problems

17. Family History
 Number of patient’s family
members
 Similar disease status
 Other diseases running the
family e.g. IHD
 Cause and age of death
 Consanguinity
Hereditary Diseases

18. Special Challenges
 SensitiveTopics
 The Right Location
 Does anyone present make the patient feel
uncomfortable?
 GainingTrust
 ChoosingAppropriateWords
 Understand the patient’s feelings related to the
sensitive nature
 Be Professional

20.  The Silent Patient
 Short periods of silence may be normal
 Allow time to collect thoughts
 Provide reassurance & encouragement
 Consider:
 You have frightened the patient
 You are dominating the discussion
 You have offended the patient
 There is a physical or mental disorder

21.  The Overly-Talkative Patient
 Allow patient to speak
 If necessary, politely interrupt and focus the
discussion
 Focus on most critical issue
 Ask specific, closed-ended questions
 Summarize the patient’s story and move on
 Don’t display your impatience

22.  The Anxious or Frightened Patient
 Look for signs of anxiety or fear
 Try to alleviate concerns & develop trust
 No false reassurance
“Everything is going to be fine”
 Identify the source of anxiety/fear
 Understand the patient’s feelings
“I don’t know why you are so anxious’

23.  The Angry or Hostile Patient
 Common feelings with stress or fear
 Understand the source of these feelings
 Respond in a professional & caring manner
 Personal Safety is a primary concern!!!
 Distance
 Assistance
 Firm but caring verbal & body language

24.  The Intoxicated Patient
 Irrational
 Altered sense of right & wrong
 May become violent
 If patient is shouting,
 increased potential for violent behavior
 listen
 don’t respond back with shouting
 have assistance for safety

25.  The Depressed or Suicidal Patient
 Know the warning signs
 Explore the specific feelings of the patient
 Be direct and specific
 Question regarding thoughts of suicide or personal
harm
 Talk openly and specifically about suicide plans

26.  The Patient with Confusing Behavior or
History
 The entire history does not add up
 Assess mental status
 Consider possible dementia or delirium
 Identify cause if possible
 Consider specific causes based upon behavior
 Confabulation
 Multiple personalities

28.  The Patient with a Language Barrier
 Extremely difficult to assess
 Enlist friends or family to act as an interpreter
 Use pre-established questions in the patient’s
language
 Language Lines

29.  Intelligence & Literacy
 Does the patient really understand your
questioning?
 History may be inaccurate
 Enlist friends or family
 Can the patient actually read?
 Read statements aloud to the patient

30.  The Patient with Sensory Deficits
 Hearing Impaired
 Does the patient read lips?
 Face patient, close to good ear
 Talk slowly and distinctly
 Sign language?
 Will a hearing aid help? Where is it?
 Blindness
 Voice and touch are critical
 Establish relationship & trust early on

31. Common Pitfalls
 Choosing to
ask lots of
questions to
obtain a history
WITHOUT also
directing initial
care or
performing a
physical exam
 Patient’s
Impression
 Not doing
anything for
me
 Why are we
wasting our
time here?
 Stop asking all
these silly
questions

32.  Using a tone of
voice that
sends the
wrong message
 “What is your
‘Problem’
TODAY Mrs.
Jones?
 “Why did you
call 911?”
 Patient’s
Impression
 He thinks I call
EMS for every
little problem
 I must have called
911 and was not
supposed to.
 I think I am
bothering these
nice people

33.  Using a tone of
voice that sends
the wrong message
 “What is your
‘Problem’ TODAY
Mrs. Jones?
 “Why did you call
911?”
 Patient’s
Impression
 He thinks I call
EMS for every
little problem
 I must have called
911 and was not
supposed to.
 I think I am
bothering these
nice people

34.  Lack of respect for
cultural, religious
or ethnic
differences
 “Why do you
people use these
home herbal
remedies?”
 “You have enough
kids. You should
consider birth
control”
 Patient’s
Impression
 This person thinks
I am a fool
 She laughs at the
traditions of my
culture
 He does not
respect my
personal decisions

35.  Poor choice of
words or using
technical terms
 How many years
has your husband
been taking these
ACE-inhibitors?
 Your wife is
experiencing
congestive heart
failure
 Patient’s
Impression
 What the heck is
he talking about?
 My wife’s heart is
failing?!?! Has her
heart stopped
yet?
 Son, could you
speak English?