History taking

Arguably, the most important step in assessing a condition, is the history taking. A story can be just as revealing as a physical assessment, since many different conditions have a distinguishable timeline of events and a distinct group of symptoms. A carefully selected list  of questions is very important, as it will give the assessor the right information to both include and exclude the likeness of different conditions.

For example, it is quite unusual that somebody suffering from BPPV will have a blocked ear on one side, with some tinnitus and hearing loss.  For this reason, if the assessor hears that a particular client is suffering these symptoms, there are already some clues that this will not likely be BPPV, but could be something such as Meniere’s disease.

From the history, the assessor can narrow the focus of the assessment, and begin to tease apart some of the finer details about what is the most likely cause for the presenting complaint.

In some cases, such as with concussion or whiplash, the history may be quite clear, whereby the trauma of an accident was clearly the cause of the problems, however, the history then becomes important with regard to the symptoms.

The presentation of the condition will be useful as a guideline to understanding which symptoms are primary symptoms and which initial treatments may be the best option.

Visit the BrainBalanz Form Section to find links to forms often utilised during the initial assessment and history taking.