Concept:

Firstly, we consider the first steps to develop a clinical history in

Physiotherapy are name and last name, address, phone number, age and
genre.

Asking the full name is importan because we can access in to the data
base and generate closer link with the patient although it would be not
necessary if the patient already had a clinical history.

The address may be important in order to know what kind of diseases the
patient would have.

Asking the phone number is also important because we may need to know
how is our patient is rehabilitating.

Age guide us towards degenerative disorders. Cancer, coronary and

cerebral infarcts, are factors to consider in the evaluation of the major.

Also in this age group we will expect a smaller range of movement. Sexual
orientation and predisposition to certain diseases: osteoporosis, breast
cancer, prostate or gynecological alterations are linked to gender.

The combination of age and sex is important in many cases, such as that of
a mature age with a possible visceral or neoplastic origin.
 CLINICAL DIAGNOSIS

1.- Anamnesis:

Personal history:

1.1. Previous diseases: The personal history is very important for the
functional prognosis, the rehabilitation process and the prevention of a
greater valence.

Other diseases:
Family pathology: This will determine the composition of the family group
and the characteristics of each one of them, such as age, vital status and
their pathological antecedents such as allergies, congenital and hereditary
diseases. In case of having dead relatives, the cause will be noted.

1.2. Surgical interventions:

Date and type of intervention:

The patient is pregnant or thinks she might be:
Previous treatments for the current problem:
The patient found improvement:
Other treatments:
Description of the current process:
Patient expectations:
Expectations of the family or caregiver:

2.- Health habits:

The patient is a smoker:

Number of cigarettes / day:

The patient is ex-smoker:

Number of cigarettes / day:.

The patient is a habitual drinker:

During days / week.
Perform exercise:
During days / week.

3.- Exploration:

Physical exploration: The physical examination in rehabilitation should

look for the problems associated with the current illness and that
contribute to increase the disability; Likewise, it must detect the residual
capacities from the physical, psychological and intellectual point of view,
since these are the bases to initiate a rehabilitation program.
Weight:
Size:
Body Mass Index (BMI):
Ethnicity:
Complementary explorations: (Radiography & Ecography)
Relevant findings:

4.- Pharmacotherapy:

The patient has prescribed for the current problem

It self-medicates with
Other medication:

5.- Social situation:

The patient lives with

Your work situation is.
The occupation is.
To access your usual home you have.
Use as technical aid / s.

6.- Level of functionality:

The patient has difficulty in

The patient presents difficulty for self-care in
The patient presents difficulty for home activities in
The patient presents difficulty for social activities in.
7.- Diagnosis:

Main diagnosis of Physiotherapy

8.- Treatment plan:

Physiotherapy:
Detailed description of Physiotherapy:
Tasks associated with Physiotherapy 1:
Tasks associated with Physiotherapy 2:
Initial objectives:
Expectations of the physiotherapist:
Observations of the physiotherapist:
Informed consent:
Physiotherapy recommendations: