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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?

Did it start with any specific incident?

If yes, select which event:

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?

Additional Information

3.

What eases the pain or makes it better?

Other / Additional Information (please state

Do you have stiffness with pain?

4.

What is your general health like?

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?

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)]

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?

10.

Do you have any of the following symptoms?

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

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?

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?

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

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

If yes (please describe)

14.

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

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?

If yes (please describe)

Does the problem ever wake you during the night?

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)?

15.

How long have you had the pain?

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

Pain associated with

16.

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

17.

Have you had this problem before?

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?

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

If yes (please specify below)

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

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?

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?

Any restricted/limited movement?

Any other information

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

Any restricted/limited movement?

Any other information

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

Any restricted/limited movement?

Any other information

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

Any restricted/limited movement?

Any other information

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

Any restricted/limited movement?

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

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CORPORATE WELLNESS

CapitaHealth is a premier provider of physical therapy and corporate wellness programmes in Nigeria. Our physiotherapists are licensed and reputable clinicians dedicated to providing highest quality care and superior customer service.

info@capitahealth.com

https://capitahealth.com

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