Here is the beginning to my subjective physical therapy examination. I expand on different areas as I see appropriate and I will discuss somewhat below.
Question 1: Why are you here?
-This gives me a lot of information, most of the information I need hopefully. I like to hear a patient’s story and how much they have been affected by a previous diagnosis in the medical system. If the first thing I hear is “because my doctor told me to come,” or “because I have x diagnosis as seen on x-ray or MRI (or worse yet WebMD/the internet),” then I have a lot of work to do to get the person to begin to explain what they think is happening. As a patient, your opinion on what is occurring is very important. You give us the pearls of information that distinguish the true source of the pain.
Question 2: Where does it hurt? Can you describe the pain?
Question 3: Pain ratings:
-right this moment: __/10
-the worst in the last 7 days: __/10 – this question frequently comes along with the comment, “it used to hurt worse when it first happened 2 months ago” – which is indicating that the patient is healing well already – it’s amazing what time will do.
-I always follow up the question of what is the worst pain with, “when did this occur? what were you doing?”
-the least amount of pain in the last 7 days: ___/10 – unfortunately, I frequently have to follow up this question, “have you ever had 1 second in the last 7 days where there wasn’t any pain?” Most people reply yes.
Question 4: What aggravates the pain / makes it worse?
Question 5: What can you do to make the pain better?
Question 6: What activities don’t affect the pain? Sometimes this requires the reminder that an activity can increase pain several hours later in the day.
Beyond that, I ask precautionary questions, some social history (job, family roles), exercise history (what do they want to get back to?), and try to define functional limitations with quantitative measures. These include how often does it hurt, how many hours / day, how many hours of sleep are affected? What is the pain rating with specific activities.
Lastly, I finish with a subjective functional outcome measure: LEFS, UEFI, NDI, Quebec.
*Note – I have access to PMH, PSH, and Meds in my electronic medical record.