Patient History

Clinical Cornerstone:

• Taking a patient's history goes beyond data collection; it's about forging and upholding a therapeutic relationship. Actively and empathetically listening to the patient's narrative offers insights into their condition and its optimal approach to management. The essence of history-taking lies in turning into the patient's story, discerning their non-verbal cues, and steering the conversation to ensure a comprehensive, yet seamless, patient history.

• Clinicians should exercise judgment during history-taking. Adopting principles of trauma-informed care (safety, trustworthiness, collaboration, choice and empowerment, culturally responsive) could help minimize potential barriers. This might involve signposting to signal the direction of the consultation and explaining the rationale behind sensitive questions or tests.

• While history taking needs to be thorough, it does not need to be linear. Reports can be explored as the patient makes them, using care to ensure needed details are not subsequently missed. While certain topics like prior episodes of headache or neck pain, past care experiences, and recovery expectations are crucial, they might be broached at different times during the patient encounter, not just during the initial history.

• When re-evaluating existing patients, especially those presenting with new headache complaints, a thorough assessment is imperative, just as it is with new patients. Explore the patient's new headache complaint to better understand it's characteristics. Identify any relationship between the new complaint and pre-existing conditions or treatments.

​

• Sociodemographic: Age, sex (some primary headaches are more likely in women, some are more likely in men), occupation.

​

• Chief complaint: Main issues.

​

• Characteristics of Present Condition: Onset (acute/progressive), mechanism, location (unilateral/bilateral, frontal/occipital), duration (minutes, hours, or clustered), frequency (number of headaches per month), character, alleviating/aggravating factors, radiation (e.g. pain, numbness, tingling or weakness), timing (e.g. constant/intermittent, morning/end-of-day/night pain, improving/staying-the-same/getting worse), severity, associated symptoms (including symptoms that started around the same time, and any distal symptoms).

​

• Past Health History: Previous or concurrent conditions, medications, injuries, hospitalization, surgeries, and treatments. Includes orange flags: significant psychiatric symptoms or disorders (e.g., major depression, anxiety disorders, post-traumatic stress disorders [PTSD]).

​

• Narrative: How the headaches affect activities of daily living.

​

• Previous History of Headaches: Previous history of headaches (including if they were similar or different) (e.g. some primary headaches typically begin in childhood). Inquiry should also explore experience with previous treatments (effectiveness, any adverse effects).

​

• Associated Complaints: Ask about focal neurological signs. Identify any co-morbid disorders (e.g., concussion, TMD, occipital neuralgia, etc.).

​

• Health History: Previous or concurrent conditions (physical, systemic, or mental health conditions), medications, injuries, hospitalizations, surgeries, and medical treatments.

​

• Orange flags: significant psychiatric symptoms or disorders (e.g., major depression, anxiety disorders, post-traumatic stress disorders [PTSD]), volume and intensity of weekly physical activity and exercise.

​

• Family History: Genetic and familial predispositions, familial major medical history (e.g., cancer, cardiovascular).

​

• Social History: Family support, caregiver responsibilities, role of family or caregivers in care.

​

• Review of Systems: Comprehensive review of body systems to identify any related or unrelated symptoms (neurologic, cardiovascular (including hypertension), genitourinary, gastrointestinal, muscles and joints, eyes/ears/nose/throat, respiratory, skin, mental health, bone density, medications, pregnancy, children).

​

• Psychosocial Assessment:

  • Beliefs and perceptions: Negative beliefs about the prognosis, fear of movement or re-injury, misconceptions about the nature of the pain, or poor expectations of recovery.

  • Behavioural factors: Avoidance behaviors, reduced activity levels, over-reliance on passive treatments, or high self-reported disability levels.

  • Social or environmental factors: Lack of social support, work-related issues, or family pressures.

​

• Lifestyle Assessment: Nutrition, exercise (type, duration and frequency), hobbies, sleep, stress; smoking, alcohol, and recreational drug use.

​

• Occupational History: Type of work they do (sedentary, physical labour, etc.), ergonomics of workplace, other work stressors (including social environment), any time off due to LBP, any work accommodations/modifications.

​

• Social determinants of health: Employment, childcare, education, nutrition, housing, domestic violence, child maltreatment, discrimination, isolation.

​

• Goals and expectations: Goals for treatment, expectations from intervention.

​

Documentation: Record all findings in the patient record.