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Details Of The Chief Complaint

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Details Of The Chief Complaint

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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:

  1. When, or approximately when did the problem begin?
  2. What were you doing when the problem began (OR #3)
  3. Can you think of a possible cause?
  4. Have you ever had anything like this before?
  5. Can you point to the exact location of your symptoms? Please describe them.
  6. Does the pain radiate to any other part of your body?
  7. Do you have complaints in any other part of your body?
  8. Can you describe the sensation? ( Dull, sharp, burning, aching, electric shock, throbbing, shooting, gnawing, stabbing, numbness, tingling)
  9. How would you describe the intensity? ( Mild, moderate, severe, other)
  10. Has your condition been constant, or off and on throughout it’s duration? Please explain.
  11. Has your condition been getting better, worse, or has it remained about the same?
  12. Have you found anything that makes it better? (Rest, certain positions, morning, evening, other)
  13. Have you found anything that makes it worse? (Activities, positions, coughing, sneezing, straining, morning, evening)
  14. Have there been any changes in your bodily functions? (Vision, urination, respiration, defecation, digestion, balance, other)
  15. Has your condition affected your daily activities in any way?
  16. Have you tried any store bought or homemade remedies?
  17. Have you sought any other professional care for your condition? What were the results? (Poor, fair, good, excellent, not sure)
  18. 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.

About the Author:

I was introduced to Chiro.Org in early 1996, where my friend Joe Garolis helped me learn HTML, the "mark-up language" for websites. We have been fortunate that journals like JMPT have given us permission to reproduce some early important articles in Full-Text format. Maintaining the Org website has been and remains my favorite hobby.

3 Comments

  1. Chiropractic Works December 9, 2009 at 7:47 pm

    frank, thanks for posting this. I can tell you that documentation is not my strong point, but small chunks like this broken down is very helpful

  2. Frank December 9, 2009 at 8:07 pm

    The Chief Complaint form was developed by Paul Mullen, DC and is taught as one component of Physical Exam at Palmer College.

  3. Seattle Chiropractor November 10, 2010 at 9:50 pm

    Great basic info!

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