Details Of The Chief Complaint
SOURCE: A Chiro.Org Editorial
By Paul D. Mullin, D.C.
Before we examine any new patient, we need to gather a detailed history, particularly of the current complaint(s). I want to thank Paul D. Mullin, D.C. of Palmer College for suggesting these 18 questions, to help DCs in gathering the information they need to clearly understand a patient’s issues.
These questions are a good example of the interviewing skills required of any doctor:
- When, or approximately when did the problem begin?
- What were you doing when the problem began (OR #3)
- Can you think of a possible cause?
- Have you ever had anything like this before?
- Can you point to the exact location of your symptoms? Please describe them.
- Does the pain radiate to any other part of your body?
- Do you have complaints in any other part of your body?
- Can you describe the sensation? ( Dull, sharp, burning, aching, electric shock, throbbing, shooting, gnawing, stabbing, numbness, tingling)
- How would you describe the intensity? ( Mild, moderate, severe, other)
- Has your condition been constant, or off and on throughout it’s duration? Please explain.
- Has your condition been getting better, worse, or has it remained about the same?
- Have you found anything that makes it better? (Rest, certain positions, morning, evening, other)
- Have you found anything that makes it worse? (Activities, positions, coughing, sneezing, straining, morning, evening)
- Have there been any changes in your bodily functions? (Vision, urination, respiration, defecation, digestion, balance, other)
- Has your condition affected your daily activities in any way?
- Have you tried any store bought or homemade remedies?
- Have you sought any other professional care for your condition? What were the results? (Poor, fair, good, excellent, not sure)
- Do you have any other symptoms or problems you’d like to discuss?
If you found this helpful, you might also enjoy this Chapter on gathering a Basic Patient History.