Professional Documents
Culture Documents
Screening
Examination
Examination
in physical therapy
practice includes taking the client's
history, reviewing the body systems
for potential pathology, and
performing specific tests and
measures guided by the initial
screening, patient/client history,
professional judgment, and relevant
clinical findings.
Evaluation
Evaluation,
nonverbal communication
Appropriate
nonverbal communication
Five
verbal communication
Nonverbal
communication plays a
key role in jthe . interview process,
but verbal communication is critical
for eliciting responses needed for a
medical history and identification of
health risks
Open ended questions/ closed ended.
Cont
Cont
Cont
.
Stress Assessment
During
individuals come to a
screening to get help but are
embarrassed to admit that they are
experiencing significant psychosocial
problems. It is important to screen
for possible violence since an
individual may be experiencing
significant stress in personal
relationships.
Cont
The
Family History
Do you hove o family history of:
__Blood pressure
__Stroke
__Concer
__Diabetes
__Allergies
__Arthritis
__Alcoholism
__Mental illness
__Seizure disorders
__Kidney disease
__Other
General Health
Weight:__
(normal range __, overweight__, underweight.
__Fatigue ___Weakness __Malaise __Fever
__Illness
Immunizations
.No_Are immunizations current? Yes.. What is your
travel history? __
Birth History
Vaginal:____ C-seclion:_________
Full-term? Yes__ No_ Any complications:__
Medications
list prescription and over-the-counter drugs:
Medical History
Serious accidents (date, injury, length of care):.
Hospitalizations (date, injury, length of care):
Surgeries (dale, injury, length of core):.
Serious illness (date, injury, length of care):
Vision
____Glasses
__Any problems with vision
Ears
___Earaches __Infections __Discharge
from ear __Ringing (tinnilis) __Dizziness
(vertigo)
Nose and Sinuses
__Discharge from the nose or sinuses
__Sinus pain
__Unusual and frequent colds __Change
in sense of smell
Mouth and Throat
___Pain
___Toolhoche
__Lesions or sores on the mouth or throat
__Changes in the mouth or throat
__Altered taste
__Jaw pain
Neck
____Neck pain
__Limitations in neck movement
__Lumps, swelling, tenderness, or other
discomfort
Respiratory System
____History of asthma __Chest pain
/Shortness of breath LCougri ___Wheezing
Cardiovascular System
____Pain
____Pain near heartwith or without exertion __Dizziness
when standing up ;__Personal history of any heart problems
__Problems breathing when sleeping
k
Peripheral Vascular System
' ____Coldness
____Coldness __Numbness '.^Tingling
__Swelling of legs or hands '
Pain in legs __Discolored
hands or feel ____Voricose veins __History of vascular
problems
Gastrointestinal System
__Changes in appetite
__Food intolerance
__Heartburn
__Abdominal pain
__Nausea and vomiting
__Flatulence (gas)
Frequency of bowel
movement ___
__Recent changes in stool
__Constipation or diarrhea
__Rectal bleeding
__Rectal conditions
__Use of antacids or
laxatives
__High fiber in diet
Urinary System
Frequency of urination.__
__Problems with urgency
__Pain with urination
__Unusual color
__.Other problems
__For women: Kegel exercises post-pregnancy
Male Genital System
__Penis or leslicular pain __Sores or lesions __Discharge
__Lumps __.Hernia
Female Genital System
Menstrual history (last period, duration; cycle): _
Pregnancy history: ___________________ ___Vaginal itching
__Discharge
Age of menopause __Menopausal signs or symptoms
__Postmenopausal bleeding.
Musculoskeletal System
__History, of arihrilis; gout; joint poin, swelling, or
ss __Gait problems (problems with walking) __Problems with coordinatio
Neurological System
___History ot seizures, blackouts, strokes, fainting;
headaches __Motor problemstics, tremors, paralysis, or
ess, tingling ._.Memory: loss, disorienlalion __Mood changes __Depressi
Hematologlc System
____Bleeding problems
__Excessive bruising
__Lymph node swelling
__Exposure to toxins and radiation
__Blood transfusions and reactions_________
Endocrine System
__History of diabetes
__Thyroid disease
/
__Intolerance to heat and cold
__Change in skin pigmentation and texture
__Excessive sweating
__Abnormal relationship between appetite and weight (describe)
.Abnormal hair distribution '
.Nervousness
.Tremors
.Need for .hormone therapy
s
Thanks