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HISTORY TAKING AND SYMPTOM ANALYSIS WITH OPQRST FRAMEWORK

To enable us to undertake a comprehensive history taking with a thorough symptoms analysis, we use a well-established framework and follow a systematic approach to gather relevant information about your presenting complaint. This guides our virtual assessment and examination during the telehealth consultation which is conducted through a HIPPA compliant videoconferencing.

This comprehensive examination is designed to gather clinically relevant information and takes around 10 - 15 minutes to complete.
Please be thorough when filling out your examination form and ensure you answer all relevant questions.
The more detail you provide, the better equipped we are to advise you.
If a question is not applicable, please write NA (Not Applicable) as your answer.
Please ensure you have read and agree to our Terms and Conditions before commencing your examination.
If you think you have a medical emergency, please cease this consultation and dial your local emergency number immediately

PLEASE, IF YOU HAVE ANY MEDICAL EMERGENCY, DO NOT GO AHEAD WITH COMPLETING THIS QUESTIONNAIRE. PLEASE CALL THE EMERGENCY NUMBER IN YOUR LOCAL AREA. THANKS!

1.

When did pain or the problem start?

Did it start suddenly or gradually?

Sudden onset

Gradual onset

Did it start with any specific incident?

Yes

If yes, select which event:

accident

fall

lifting

others

What do you think caused the pain?

(If unsure, think about 1 or 2-day period prior to the onset of the pain)

2.

What activities provoke/aggravate/increase/worsen your pain?

Sitting

Bending forwards

Lifting

Carrying

Twisting your back

Wearing shoes & socks

Standing up from a seated position

Picking object(s) up from the floor

Walking

Changing directions when walking

Jogging

Coughing, sneezing or laughing

Driving

Getting in & out of the car

Reversing the car

Using the car pedals

Washing dishes

Vacuuming or sweeping floor

Reading in bed

Rolling in bed

Lying on your stomach

Standing on one leg

Hanging clothes on the line

Certain work activities

Additional Information

3.

What eases the pain or makes it better?

Lying flat on your back

Lying on your stomach (i.e. face down)

Lying on your right side

Lying on your left side

Walking

Sitting

Massage

Heat treatment (e.g. hot packs, hot showers or baths)

Ice treatment

Doing certain stretches or exercises

General movement

Taking anti-inflammatories

Other (please describe below)

Other / Additional Information (please state

Do you have stiffness with pain?

Yes

4.

What is your general health like?

Currently ‘well’

Currently ‘unwell’

If you are unwell (please explain)

5.

describe your pain (e.g. sharp , acute, throbbing, shooting etc , describe your pain in your own words)

6.

Number of episodes in a day

7.

Where is the pain located in your pain ?

Please states SPECIFIC AREA where you have the pain: ( e.g. left lower back , right lower back etc)

Is your problem in the right limb, the left limb, or in both limbs?

Right Limb

Left Limb

Both Limbs

8.

Do you get any pins and needles or numbness in any other part of the body?

[If so, please select all the appropriate location(s)]

Lower Back

Abdomen

Buttock

Hip / Groin

The saddle region (i.e. under your underwear)

Thigh

Lower Leg (i.e. calf / shin)

Foot / Ankle

More Information (if you can be more specific or have the above symptoms in multiple areas or only at certain times, please describe)

9.

Have you had the problem in the past?

Yes

10.

Do you have any of the following symptoms?

(Please select all relevant signs and symptoms you are currently presenting)

A pulsating sensation near your navel **

Loss of bowel or bladder control **

Unexplained weight loss

Loss of appetite

Severe abnormal tiredness

Night sweats or fevers

Unexplained pain in your abdomen or chest

Stomach cramps

Nausea

Vomiting

Blood in stools / urine

Pain with urination

Frequent or difficult urination

Diarrhoea

Incontinence

Rectal bleeding

Discharge

Additional Information (If you have any of the above, please give details with description)

IMPORTANT: If you have a pulsating sensation near your navel/belly button or loss of bowel or bladder control, please immediately seek medical attention as these symptoms may in some cases be warning signs of a serious condition requiring immediate treatment.

11.

(select any applicable to you) :

Do you have any restricted joint movement?

stiffness

swelling

wasting

deformity

limp

weakness legs

tingling

numbness

Please state part of the body where you any of the selected above is present

12.

On a pain scale of 0 to 10 (0 being no pain and 10 being the worst pain imaginable), what is your pain level like on a good day?
[state the pain level]

On a pain scale of 0 to 10, what is your pain level like on a bad day?
[state the pain level]

13.
What is your occupation and what does it involve physically?

Do you normally exercise or play sport?

Yes

No

If yes (please describe what you normally do and how frequently)

Has this injury affected your work, exercise or normal daily activities?

Yes

No

If yes (please describe)

14.
How does this problem feel first thing in the morning when you are getting out of bed?

Same

Better

Worse

Additional Information (please specify)

What is the general pattern of the pain over the course of a typical day?
(Please explains e.g. stiffness/pain in the morning, only sore with activity, pain/stiffness eases with movement, then most achy on returning home from work, relieved during weekends/holidays etc.)

Do you have any trouble getting to sleep at night due to this problem?

Yes

No

If yes (please describe)

Does the problem ever wake you during the night?

Yes

No

if yes (please describe how often you wake & if it only wakes you if you move a particular way or if it wakes you even without moving)

Does your pain get better with activity (i.e. it ‘warms’ up) or does it progressively increase during activity (and may sometimes force you to stop)?

Gets better with activity (i.e. it warms up)

Gets worse with activity

Other (please specify)

15.
How long have you had the pain?

Is your pain constant or episodic (comes and goes) ?

Constant

Episodic (comes and goes)

Pain associated with

sleep

meals

work

activities

and menstrual cycle

16.
Is it the pain same, better or worse since it started?

Same

Better

Worse

17.
Have you had this problem before?

Yes

No

If yes, please state your previous diagnosis (if you had one)

Past medical History and other conditions.

Do you have or have you previously had any other medical conditions?

Yes

No

Medication (prescribed medication, over the counter, herbal medicine, contraception, internet, cream/gel, injection inhaler)
Are you taking any specific medications for this problem?

Yes

No

If yes (please specify below)

Have you had any operations, illnesses or other injuries in the past?

Yes

No

If yes (please specify)

When was it?

Previous Treatment / Investigations [if applicable, please state the treatment and investigation, x-rays, CT-scan, MRI, blood tests and the results]

Have you had treatment for this problem in the past, or have you tried any treatments for this episode? (If so please describe)
What type of treatment?

When did you have this treatment?

Has it helped?

How many treatment sessions?

(If you are female) are you pregnant?

Yes

No

18.
If you (or someone you know) feel around the painful area firmly with your (or their) fingers, do you feel any pain/soreness? [which area(s) did you feel the soreness or pain]

19,
Bend forward as shown in the image. Do you have any pain?

Yes

No

Any restricted/limited movement?

Yes

No

Any other information

Stand up straight and bend backwards as shown the image. Do you have any pain?

Yes

No

Any restricted/limited movement?

Yes

No

Any other information

As shown in the image, bend to your right side. Do you have any pain?

Yes

No

Any restricted/limited movement?

Yes

No

Any other information

As shown in the image, bend to your left side. Do you have any pain?

Yes

No

Any restricted/limited movement?

Yes

No

Any other information

Do you have increased pain when performing the manoeuvre as shown in the image?

Yes

No

Any restricted/limited movement?

Yes

No

If yes, which leg(s)?

Any other information

Any additional information about your examination?

I acknowledge that I have answered all questions correctly and have read and agree to CapitaHealth's terms & conditions

Yes (I agree)

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