This document provides guidance on taking a thorough patient history. It outlines the key components of a patient history, including present history, past history, medical history, drug history, surgical history, family history, occupational history, and personal history. Taking a complete history is important for understanding the patient's condition, making an accurate diagnosis, evaluating severity, and directing the focus of the examination and treatment.

1. HISTORY TAKING
DR. DARSHAN PARMAR (MPT-NEURO)

2. History is the first information about the patients condition.
Therapist decide the relevance of the information based on experience.
If the patient is not able to describe then a close family member who is well acquired with the
patient’s condition should describe the complaints to the therapist.
History taking helps us to know the disease, helps us in differential diagnosis and evaluating the
severity of the disease.
It direct the focus of the therapist towards examination of particular things.

3. General Guidelines
Gain confidence of the patient
Let patient express himself by his own words
Eye contact is important
Appropriate distance and position  Safety, Respect and Personal Zone
Use simple language which is easy to understand
Quastions should be Open ended or Closed ended.

4. PRESENT HISTORY
It should be mentioned in chronological order.
Course of the dysfunction right from the day of onset, duration and progression should be
mentioned.
Site and duration of symptoms should be noted.
Every events taken place from onset  till date should be mentioned like Patients observing
symptoms for first time, its progression , taking patient to hospital/clinic for evaluation, doctors
examination, investigation, suggestions and prescriptions, treatments like physiotherapy till
date, follow ups should be mentioned in it.

5. PAST HISTORY
History of similar event taken place in the past and which has been cured should be mentioned
here.
Its help us to know the recurrency of the disease, know treatment effectiveness and decide the
treatment accordingly.

6. MEDICAL HISTORY
Information regarding consultation of the doctor or other healthcare professional
Any disease which are comorbid and affects the outcome of our treatment should be mentioned
here. Like HTN, DM, Hyper/Hypothyroidism, High Cholesterol level etc. should be mentioned
here.

7. DRUG HISTORY
Current drug history with the dosage should be mentioned here.

8. SURGICAL HISTORY
Any surgery which is relevant to the current disease should be mentioned here.
Date of Admission, Date of operation, Procedure and Date of discharge should be written form
the discharge card.

9. FAMILY HSITORY
It is asked to identify hereditary disease in the family
Knowledge of health and fitness of the spouse and other family members can be useful in
deciding certain discharge parameters.
It also consist of number of patient’s family members

10. OCCUPATIONAL HSITORY
Its should be asked for details of occupational related information, specifically like kind of work
an individual has to perform.
Even it help us to identify occupational related disorders.
Also helps us to set back to return to occupation goal as our treatment goal and in some of the
disease due to poor prognosis if back to job is not possible the other modifications in the job or
change in job according to patients condition can be created.

11. PERSONAL HISTORY
Personal history like Tobacco chewing, Smoking, Alcohol consumption should be mentioned
here.
History of Hobbies, patients status of education, hours of sleep and exercise should also be
mentioned.
Marital history should also be mentioned.

12. REFERENCE
Physical Rehabilitation: Sullivan
PT in Neurological Conditions: Megha Sheth
Brain’s Disease of the nervous system: Michael Donaghy