Subjective Assessment Template

History of Present Condition (HPC)

O – Onset

• Any particular event that caused the pain? Or, has is been a gradual onset?

L – Location

• Be very specific in terms of anatomy

D – Duration

• How long has the pain been present? Is it present all the time? How long do flare ups last?

C – Characteristics

• Type of pain? Burning? Dull Ache? Don’t ask leading questions.

A – Alleviating/Aggravating Factors

• What, if anything, makes the pain better or worse? Leading questions are okay here. VAS scale – be specific here too. If it is painful walking downstairs, how painful? Are they or have they received treatment in the area before.

R – Radiating

• Is the pain local or radiating to another area or joint? Any bilateral issues?

T – Temporal Pattern

• 24 hr behaviour, morning, afternoon, evening? How does the pain feel during these phases of the day? Does it interfere with sleep?

S – Severity

• Do we need to manage pain relief? Or can we start strengthening/implementing weight bearing strategies?

Past Medical History (PMH)

General Health

If you have seen the patient before be observant of possible changes. If you haven’t, have they noticed a recent decline and do they know a reason why?

Past Illnesses & Allergies
T – Thyroid
H – Hypertension
R – Rheumatoid Arthritis
E – Epilepsy
A – Asthma
D – Diabetes
S – Steroid

Hx – Cancer
Environmental Allergies – may affect when you work with them

Previous Hospitalisation to Medical Appointments

Related or not – decide what is relevant to include

Medications

Prescribed or Over the Counter, e.g. NSAID’s

Diet 

Can help establish attitudes towards nutrition and exercise. 

Sleep 

Any problems sleeping? Related to injury or a yellow flag

Family History

Hx of Cancer or anything that may be of relevance to injury. 

Medications

What? – Name of medication 

Why? – Reason for medication

What dosage?

Possible side effects?– could impact when you train them, how you monitor intensity, etc. 

Contraindications?

Painkillers? How much? Could inhibit pain during assessment.

Social & Family History

What are the patients expectations?

Think about age – age related pathology?

Is it work related? Think about work or education.\

Home situation – marital status, children, dogs, etc.

Leisure – sports, positions played, training patterns

Consider – Has anyone else in the family had similar complaints?

Aggravating/Alleviating Factors

Aggravating

Daily Life – stairs, driving, kettle, showering, reaching, twisting, turning, medications, etc. 

Work  – does the problem impact work? Can work be modified to help with problem? 

Exercise – have they modified training in any way?

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Alleviating

Activities – rest, moving, stretching

Self-Management – ice, heat, NSAID’s, taping, bandage, etc.

Lifestyle – better on weekends? 

If something is alleviating – 

How long does it take to alleviate?

How long is alleviation?

How frequently have they applied alleviations?

Body Chart

Identify area of pain 

Can indicate – paraesthesia, stiffness, weakness, referred pain.

Indicate type of pain & intensity (can use VAS)

Identify abnormal sensations – Red Flags

Severity & Irritability

Severity

Low – Could tolerate tissue loading

Moderate

High – Work on managing pain 

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Irritability

Low – difficult to provoke symptoms

Moderate – certain movements provoke symptoms

High – very easy to provoke symptoms