1. History Taking Process DX 611 Orthopedics
James J. Lehman, DC, MBA, DABCO
University of Bridgeport College of Chiropractic

2. Introduction Make eye contact and shake hands
Demonstrate an interest in the patient

3. A Time to Listen and Learn…
Present time consciousness is essential
Be with the patient

4. First Impression is a Lasting One
Build the doctor/patient relationship
Commence therapeusis

5. Closed End v. Open End History
Intake forms
Interview

6. Introductory Materials
Date
Age
Sex
Race/ethnic origin
Birthplace
Occupation

7. List the Sources of…
Referral
History
Reliability

8. Main Parts of History Chief complaint Present illness
Past health history
Current health status
Family
Psychosocial
Review of systems

9. History Taking Process
Chief complaint
Present illness
Past history

10. Comprehensive v. Limited History
Complicated condition
Obese with diabetes
Loss of weight and fatigue
Poor response to care
Specific complaint
Stiff neck
Muscle strain
Strain

11. Comprehensive History
Medico-legal
Motor vehicle accident
Work related injury

12. Sequence Begin with a general question.
Please tell me what brings you into the office?

13. Sequence Next, ask direct questions without leading the patient.
Where is the pain?
What does it feel like?

14. Direct Questions Does the pain move around?
Show me. Point to the pain.

15. Graded Response
How long can you play before you get the pain in the back?

16. Spinal Stenosis
How far can you walk before you have to stop?

17. Inability to Describe Symptoms
Is your pain burning, aching, sharp, pressure-like, stabbing, shooting, or what?

18. Avoid Confusion Ask one question at a time…
You injured your back while lifting a box?
How much did the box weigh?

19. Avoid Medical Terminology
Use language that the patient can understand.
Try to use their words…

20. Sensitive Questions Tobacco Recreational drugs Alcohol
Domestic violence
Psychiatric illnesses

21. Special Challenges Silence v Overtalkative
Collecting thoughts
Determining trust
Recounting present illnesses
Check non-verbal signs
Give free-reign for 5 minutes
Show interest
Ask questions
Focus discussion
Be polite
Re-evaluate goals

22. Angry or Hostility In pain Not in control Frightened Loss of income
Tired of waiting

23. Accept the Feelings Defuse the Anger
Once the patient calms down, you should continue…

24. Illiteracy
May have difficulty completing the intake forms

25. Depression Identify and Explore Manifestations
Fatigue
Weight loss
Insomnia
Mysterious aches and pains

26. Neuro-musculoskeletal History
Onset
Palliative/provocative
Quality of pain
Referred or radiating
Severity of pain
Timing and treatment

27. Final Questions
Is there anything else that is bothering you?

28. Final Questions
What do you expect me to do for you?

29. Acute Condition Pain is the most outstanding feature Rubor Dolar Tumor
Calor

30. Chronic Condition
Pain is no longer the most outstanding feature but stiffness, weakness, and/or loss of sensation.

31. History Taking Exercise
O,P,Q,R,S,T