Chief Complaint History

Question 1

CCH anagramm

Answer 1

LOCQSMATT

Question 2

L

Answer 2

Location

Left or right?

Upper, Middle, Lower?

Does it radiate? How far and where?

Question 3

O

Answer 3

When did it start? Gradual or sudden?

What was the cause?

What was the Mechanism of Injury? (three types: known, unknown, knows when it comes on)

Question 4

C

Answer 4

Chronology

Timing
Is it constant? 24 hours? interrupt sleep?
Is it intermittent?

Associated with specific circumstances (food and activities)
If there are 2 areas of pain break them apart and get seperate timing for them

Question 5

Quality

Answer 5

Describe pain/symptoms for each area of complaint

If unusual use own patients words

Question 6

S

Answer 6

Severity
Patient Specific Functional Scale (0-10) for 3 ADL’s

Oral Pain Scale: Pain scale (0-10) for onset, average and current levels

Question 7

Modifying Factors

Answer 7

What increases or decreases symptoms
Any mechanical sensitivities (Extension, flexion, rotation)
Certain postures
Rest help? Ice, heat medication?

Question 8

A

Answer 8

Associated symptoms
Additional specific questions are asked based on what the patient presents and the doctor thinks may be going on
(pain, numbing, tingling, weakness, cold, sexual function, menses)

Question 9

T

Answer 9

Treatment

has the patient seen anyone else for this complaint yet?
who, when what?

Question 10

T

Answer 10

Treatment goals
Does patient’s goals match your goals you have for them?
If long standing problem why did they come now?

Question 11

Aspects of personal history

Answer 11

Occupation
Exercise
Hobbies 
Diet
Sleep
Bowel and bladder

Question 12

Alcohol

Answer 12

“Do you ever drink wine, beer, or other alcohol?”

how many times have you drinken 4-5 drinks on one occasion

Question 13

Smoking

Answer 13

How much, how long

Know pack years: 1 pack every day for 20 years is 20 py. 2 packs every year for 20 years is 40 py.

Question 14

Drugs

Answer 14

What?
How long?
Any IV drug use?

Question 15

Describe Living Situation

Answer 15

Describe family, living situation

Question 16

Intimate partner violence

Answer 16

“Because domestic violence is so common in our society, we ask this of all our new patients”

“Are you currently or have you ever been in a relationship where you were physically hurt, threatened or made to feel afraid.”