THE CORE INTERVIEW

HISTORY OF PRESENT ILLNESS

Chief Complaint (Onset)
• Tell me why you are here today
• Tell me about your injury
Alternate questiom What do you think is æusing your problem/pain? FUPs:
How did this injury or illness begin?
Was your injury or illness associated with a tall, trauma, assault, or repetitive activity (e.g.. painting. cleaning, gardening.
filing papers. driving)?
Have you been hit, kicked, or pushed? (For the therapist: See text [Assault] before asking this question.) When
did the present problem arise and did it occur gradually or suddenly?
Systemic disease: Gradual onset without known cause.
Have you ever had anything like this before? It yes. when did It occur?
• Describe the situation and the circumstances.
How many times has this illness occurred? Tell me about each occaslon.
• Is there any difference this time from the last episode?
• How much time elapses between episodes?
• Do these episodes occur more or less often than at first?
Systemle disease: May present in a gradual, progressive. cyclical onset: worse. better. worse.
PAIN ANO SYMPTOM ASSESSMENT
• Do you have any pain associated with your injury or illness? If yes, tell me about lt.
Location
• Show me exactly where your pain is located.
FOPS: Do you have this same pain anywhere else?
• Do you have any other pain or symptoms anmhere else?
• It yes, what causes the pain or symptoms to occur in this other area?
Description
• What does it feel like?
FOPS: Has the pain changed in qualit% intensity, frequency, or duration (how long it lasts) since it first began?
Pattern
• Tell me about the pattern of your pain or symptoms
Alternate question: When does your (name the body part) hurt?
Alternate question: Describe your paint symptoms from first waking up in the morning to going to bed at night- (See special
steep-related questions that follow.)
FUPs: Have you ever experienced anything like this before? if
yes, do these episodes occur more or less often than at first?
• How does your pain/symptom(s) change with time?
• Are your symptoms worse in the morning or in the evening?
Frequency
• How often does the pain/symptom(s) occur?
FUPs: Is your pain constant* or does it mrne and go (intermittent)?
• Are you having this pain now?
• Did you notice these symptoms this moming immediately after awakening?
Duration
• How long does the pain/symptom(s) last? Systemic disease: Constant-
Intensity
• On a scale from O to t O, with O being no pain and O being the worst pain you have experienced with this condition , what
level of pain do you have right now?
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 Alternate question: How strong Is your pain?
1 Mild
2 — Moderate
3 — Severe
FUPs: Which word describes your pain right now?
Which word describes the pain at its worst?
Which word describes the least amount of pain? Systemic disease: Pain tends to be intense.

Associated Symptoms
Whal other symptoms have you had that you can associate with this problem?
FUPs: Have you experienced any of the following?

O Blood in urine, stool, vomit, mucus Headaches O Unusual fatigue. drowsiness

O Dizziness, fainting. blackouts O Cough, dyspnea CI Joint pain
O Fever. chills. sweats (day or night) Dribbling or leaking urine Difficulty
swallowing'speaking
O Nausea, vomiting, loss of appetite O Heart palpitations or fluttering O Memory loss
O Changes in bowel or bladder O Numbness or tingling O Confusion
O Throbbing sensation/pajn [n belly or anywhere else O Swelling or lumps anywhere O Sudden weakness
O Skin rash or other skin changes Problems seeing or hearing D Trouble sleeping
Systemic disease: Presence of symptoms bilaterally (e.g.. edema, nail bed changes, bilateral weakness, paresthesja, tingling,
burning). Determine the frequencyi duration, Intensity, and pattern of symptoms. Blurred vision. double vision. scotomas
(black spots before the eyes). or temporary blindness may indicate early symptoms of mult iple sclerosis (MS), cerebral vasct
•lar accldent (CVA). or other neurologic disorders
Aggravating Factors
What kinds of things affect the pain?
FUPs: What makes your pain/symptoms worse (e.g.. eating, exerdse, rest, specific positions, excitement* stress)?
Relieving Factors
What makes it better?
Systemic disease: Unrelieved by change in position or by rest.
How does rest affect the pain/symptoms?
FUPs: Are your symptoms aggravated or relieved by any activities? If yes, what?
How has this problem affected your daily life at work or at home?
How has il affected your ability to care for yourself without assistance (e.g.. dress, bathe, cook. drive)?
MEDICAL TREATMENT AND MEDICATIONS
Medical Treatment
What medical treatment have you had for this condition?
FUPs: Have you been treated by a physical therapist for this condition before? If yest
When?
0 Where?
How long?
o
What helped?
o
What didn't help?
o
Was there any treatment that made your symptoms worse? If yes, please elaborate.
Medications
o
Are you taking any prescription or over-the-counter medications?
FUPs: It no, you may have to probe further regarding use of laxative* aspirin. acetaminophen (Tylenol), and so forth- If yes:
o
What medication do you take? How often?
What dose do you take?
o
Why are you taking Ihese medications?
When was the last time that you took these medications? Have you taken these drugs today?
Do the medications relieve your pain or symptoms?
how soon after you take the medications do you notice an improvement?

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 Do you notice any increase in symptoms or perhaps the start ot symptoms afier taking your medication(s)? (This may occur
30 minutes to 2 hours after ingestion
If prescription drugs, who prescribed them for you?
How long have you been taking these medications?
' When did your physician last review these medications?
Are you taking any medications that weren't prescribed for you?
If no, fottow•up with: Are you taking any pills given to you by someone else besides your doctor?

CURRENT LEVEL OF FITNESS

• What is your present exercise level?
FUPs: What type of exercise or sports do you participate [n?
How many times do you participate each week (frequency)?
When did you start this exercise program (duration)?
a
How many minutes do you exercise during each session (intensity)?
Are there any activities that you could do before your injury or illness that you cannot do now? If yes, please describe
Dyspnea: Do you ever experience any shortness of breath (SOB) or lack of air during any activities (e.g.. walking. climbing
stairs)?
FUPs: Are you ever short of breath wlthout exercising?
If yes. how often?
When does this occur? Do you ever wake up at night and feel breathless? If yes, how often?
a
When does this onur?

SLEEP-RELATED HISTORY
• Can you get to sleep at night? Il no, tryto determine whether the reason is due to the sudden decrease in acüvity and quiet,
which causes you to focus on your symptoms
• Are you able to lie or sleep on the painful side? If yes. the condition may be considered to be chronic. and treatment would
be more vigorous than If no, indicating a more acute oondition that requires more conservatlve treatment.
• Are you ever wakened from a deep sleep by pain?
FUPs: If yes, do you awaken because you have rolled onto that side? Yes may indlcate a subacute condition requiring a
combination of treatment approaches, depending on objective findings Can you get back to steep?
FUPs: it yes, what do you have to do (if anything) to get back to sleep? (The answer may pro'ide clues for treatment.)
• Have you had any unexplained fevers, night sweats, or unexplained perspiration?
Systemic disease: Fevers and night sweats are characteristic signs systemic disease.

STRESS
• What major life changes or stresses have you encountered that you would associate with your injuryhllness? Afternate
question: What situations in your life are estressorsq for you?
• On a scale from O to 10. with O being no stress and 10 being the most extreme stress you have ever experienced, in general,
what number rating would you give to your stress at this time in your life?
• What number would you assign to your revel of stress today?
• 00 you ever get short of breath or dizzy or lose with fatigue (anxiety•produeed hyperventilation)?
FINAL QUESTION
• Do you wish to tell me anything else about your injury, your health, or your present symptoms that we have not discussed
yet? Alternate question: Is there anything else you think is important about your condition that we havent discussed yet?
FIJPs, Follow-up Questions

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