Body Area

Question

Head

Are you having any problems moving your jaw?

  If so, when did this start?

  What is the problem?

  Does it affect your ability to chew or eat food?

  Is your jaw making a clicking noise? (checking for crepitus)

  Have you talked with your doctor or health care provider about your jaw?

Neck

Are you having any problems moving your neck?

  If so, when did this start?

  What is the problem?

  Have you talked with your doctor or health care provider about your neck?

  Did you ever have surgery on your neck?

      If so, when was it done?

      What was the reason for the surgery?

  Are you able to bend your head down toward your chest? (flexion)

  Are you able to bend your head back and look toward the ceiling? (extension)

  Can you move your head to the right? (rotation)

  Can you move your head to the left? (rotation)

  Can you move your head to try to touch your right shoulder with your right ear? (lateral bending)

  Can you move your head to try to touch your left shoulder with your left ear? (lateral bending)

Shoulders

Are you able to freely move your arms from the shoulder?

  If not, what is the problem?

  When did this start?

  Have you talked with your doctor/health care provider about your shoulders?

  Did you ever have surgery on your shoulders?

      If so, when was it done?

      What was the reason for the surgery?

  Are you able to lift or carry things on the side that is affected?

  Are you able to shrug your shoulders (lift your shoulders toward your ears)?

  Can you lift your arms toward the ceiling? (extension)

  Can you touch your hands together behind your back? (internal rotation)

  Can you place both of your hands behind your neck? (external rotation)

  When standing up can you touch your left thigh with your right hand? (adduction)

  When standing up can you touch your right thigh with your left hand? (adduction)

  Are your shoulders making a clicking or any other type of noise when you move them? (checking for crepitus)

  Have you talked with your doctor or health care provider about your shoulders?

Elbows

Are you able to stretch out your arms? (extension)

  If not, what is the problem?

  When did this start?

  Have you talked with your doctor or health care provider about your elbows?

  Did you ever have surgery on your elbows?

      If so, when was it done?

      What was the reason for the surgery?

  Can you bend your arm at your elbow and touch your hand to your shoulder? (flexion)

Are you having any arm weakness?

  If so, when did this start?

  How much are you able to hold and carry with your arms?

  Is one arm weaker than the other?

Wrists and hands

Are you having any problems with your wrists or hands?

  If so, when did this start?

  What is the problem?

  Have you talked with your doctor or health care provider about your wrists and hands?

  Did you ever have surgery on your wrists or hands?

      If so, when was it done?

      What was the reason for the surgery?

  Are you having:

      Weakness

      Numbness

      Tingling

  Can you spread out your fingers?

  Can you make a fist?

  Have your hands or wrists changed in shape?

  Can you bend your hand toward the floor from the wrist?

  Are you able to pick up items with your hands?

  Can you “feel” your fingers?

  Do you drop things because of a hand problem?

Hips

Do you have any problems with your hips?

  If so, what is the problem?

  When did it start?

  Does it affect one hip or both?

  Have you talked with your doctor or health care provider about your hips?

  Did you ever have surgery on your hips?

      If so, when was it done?

      What was the reason for the surgery?

  Does the skin over your hips feel warm?

  Do your hips make a grating or clicking sound when you walk? (crepitus)

  Do you have pain in your hips when you:

      Walk

      Sit

      Cross the legs (adduction)

  Can you stretch out your leg at the hip? (extension)

  Can you raise your knees toward your chest? (flexion)

  Can you move your right leg out to the side? (abduction)

  Can you move your left leg out to the side? (abduction)

Knees

Do you have any problems with your knees?

  If so, what is the problem?

  Have you talked with your doctor or health care provider about your knees?

  Did you ever have surgery on your knees?

      If so, when was it done?

      What was the reason for the surgery?

  When did it start?

  Does it affect one knee or both?

  Does the skin over the knees feel warm?

  Does the tissue around the knee feel swollen?

  Can you bend your right knee? (flexion)

  Can you bend your left knee? (flexion)

Ankles and feet

Do you have any problems with your ankles?

  If so, what is the problem?

  Are your ankles swollen?

  Is the skin around your ankles red?

  Do your ankles hurt when you walk?

  Have you talked with your doctor or health care provider about your ankles?

  Did you ever have surgery on your ankles?

      If so, when was it done?

      What was the reason for the surgery?

  Are you able to move your feet toward the floor (push down on the gas pedal)? (extension)

  Are you able to point your toes toward the ceiling? (flexion)

Do you have any problems with your feet or toes?

  If so, what is the problem?

  Have you talked with your doctor or health care provider about your feet or toes?

  Did you ever have surgery on your feet or toes?

      If so, when was it done?

      What was the reason for the surgery?

  Are any of your toes swollen?

  Are any of your toes not straight?

  Do any of your toes overlap?

  Do you have any sores on your feet or toes?

  Are you able to curl your toes toward the floor? (flexion)

  Are you able to spread your toes out? (extension)

Spine

Do you have any problems with your back?

  If so, what is the problem?

  When did it start?

  Have you talked with your doctor or health care provider about your back?

  Did you ever have surgery on your back?

      If so, when was it done?

      What was the reason for the surgery?

  Are you able to walk?

  Do you use anything to keep yourself stable when you walk like a:

      Cane

      Walker

      Crutches

  Has anyone ever told you that you have one leg longer/shorter than the other?

  Are you able to bend over and touch the floor with your hands? (flexion)

  Do you have any pain or stiffness when you straighten your spine after bending over? (extension)

Do you have any problems keeping your balance?

  If so, what does it feel like?

  Have you fallen?

Have you had a change in your body height?

  If so, how tall were you?

  What is your height now?

  Did your doctor or health care provider tell you why your height has changed?

Have you ever been told that you have a spinal deformity such as:

  Lordosis

  Kyphosis

  Scoliosis

Situation

Question

Hip replacement or other hip surgery

When did you have the surgery?

What did you have done?

Are you able to walk or bear any weight on the leg that was operated on?

What are you using to make sure that you walk safely?

What does the wound/incision look like?

Are you experiencing any problems such as:

  Increased pain

  Drainage from the surgical wound

  Increased swelling around the surgical wound

  Fever

When are you going to see your surgeon again?

Are you getting physical therapy at home?

  If so, how many times a week?

Have you been told to avoid doing anything in particular?

For what reasons did your doctor/health care provider tell you to contact the office?

Knee replacement or other knee surgery

When did you have the surgery?

What did you have done?

Are you able to walk or bear any weight on the leg that was operated on?

What are you using to make sure that you walk safely?

What does the wound/incision look like?

Are you experiencing any problems such as:

  Increased pain

  Drainage from the surgical wound

  Increased swelling around the surgical wound

  Fever

When are you going to see your surgeon again?

Are you getting physical therapy at home?

  If so, how many times a week?

  Are you doing your knee-bending exercises as instructed?

Have you been told to avoid doing anything in particular?

For what reasons did your doctor or health care provider tell you to contact the office?

Spinal/back surgery

When did you have the surgery?

What did you have done?

Are you able to walk without any pain or discomfort?

Are you supposed to:

  Wear a back brace

  Walk with a cane/walker

Are you permitted to take a shower?

Are you experiencing any problems such as:

  Increased pain

  Drainage from the surgical wound

  Increased swelling around the surgical wound

  Fever

When are you going to see your surgeon again?

Are you being visited by a home care nurse?

Have you been told to avoid doing anything in particular?

For what reasons did your doctor or health care provider tell you to contact the office?

Finding

Action

Pain

Assess for the location of the pain.

Assess the level of pain using the standard 0–10 pain rating scale.

Assess for what might have caused the pain:

  Recent fall

Assess what has been done to treat the pain

Assess for any other associated symptoms such as:

  Inability to walk without severe pain (fracture or dislocation)

  Sudden shortening of one leg (dislocated or fractured hip)

Suspect fracture or dislocation and encourage to seek immediate medical attention.

Swollen joint

Assess the location of the joint

Assess for the length of time the joint has been swollen

Assess what has been done to try to relieve the swelling:

  Elevate on a pillow

  Wrap with an elastic bandage

  Apply ice

Assess the color of the skin over the joint:

  Red

  Bruised

Assess for any other symptoms:

  Fever

  Nausea

  Vomiting

Assess if there has been any change in ability to perform activities of daily living because of the swollen joint

Suspect acute joint inflammation and encourage to seek medical attention

Crepitus

Assess for the joint causing the crepitus

Assess for the length of time the crepitus has been occurring

Assess if the crepitus is associated with any pain

Suspect no acute disease process

Encourage to discuss the “noises” during the patient’s next visit to the doctor or health care provider

Numbness/tingling

Assess for the location of the numbness/tingling

Assess for the length of time the numbness/tingling has been occurring

Assess what has been done to try to alleviate the numbness/tingling:

  Elevating legs

  Removing compression stockings or gloves

  Rubbing the hands/feet

Assess for any other associated symptoms such as:

  New onset of limb weakness (stroke)

  Confusion (stroke)

  Blurred vision (stroke)

  Pain (acute venous or arterial occlusion)

  Skin over the area feels cold to the touch (acute venous or arterial occlusion)

Suspect an acute situation and encourage the patient to seek immediate medical attention

Muscle cramping/muscle spasms

Assess for the location of the muscle cramping/spasm

Assess for the length of time the muscle has been cramping/spasming

Assess for any activities that cause the cramping/spasming to occur or change in intensity

Assess for any other symptoms associated with the cramping/spasming such as:

  Nausea (electrolyte imbalance)

  Vomiting (electrolyte imbalance)

  Diarrhea (electrolyte imbalance)

Assess what has been done to relieve the cramping/spasms such as:

  Massage

  Elevation

  Exercise/stretching

Encourage to discuss cramping/spasms with doctor/health care provider soon