Musculoskeletal History of Present

Musculoskeletal History

Do you have any pain or problems with your joints? Which ones; is it on either side or just one side?
Describe the pain: Dull, aching, throbbing, shooting, brief, nagging, sharp, dull, or stiff? On a scale of 1 to
10, with 1 being the least pain you have ever had and 10 being the worst pain ever, what is your pain
level now and at the height of the pain episode?
When did this pain begin? How long does it last? Does it occur at a particular time of day? How often do
you experience this pain? Are there any triggers or alleviating factors? Does rest or position change
help? Do you take any OTC or prescription medications for pain? Do these help? Have you tried
elevating the part, applying heat and or ice, or splinting/wrapping?
Have you noticed any fever, chills, rash, sore throat, repetitive activity, or recent trauma?
Are your joints stiff? Have you noticed any heat, redness, or swelling of your joints?
Are you limited in movement of any joints? Which ones? Does any activity give you difficulty?
Do you have any problems with your muscles, such as pain or cramping? Which muscles?
If pain is noted in the calf muscles: Does the pain occur with walking? Does it resolve with rest? Have
you noticed any fever, chills, or other flu-like symptoms?
What medications, both prescription and OTC, are you currently taking? When was your last dose?
Some prescription and OTC medications can cause muscle cramps and myalgias. Be alert for
hypokalemia, hypocalcemia, and hypomagnesium. This may be related to dehydration, a result of crash
dieting, medication induced, etc.
Have you noticed any “weakness” of your muscles? If so, where? How long has it been present? Have
you noticed a change in the size of your muscles?
Do you have any bone pain? Where? How long have you had this pain? Does movement change the
pain? If so, how? Does anything specific make the pain better or worse? Have you tried any medications
including OTC medicines? What were the results?
Have you had any injuries to your bones? When, and which bones? What was the treatment? Do you
have any deformities? Does the deformity affect a joint and its mobility? Any previous sprains or strains?
Which part of the body? How was the sprain or strain treated?
Have any of your previous injuries caused lingering problems? Any limitations of your daily activities due
to the previous injury or pain?
Do you have any back pain? Show me where your back hurts. Does the pain radiate? Where? Describe
the pain: Is it shooting, dull, aching, stabbing, etc.? Have you noticed any numbness or tingling of the
lower extremities? Do you limp? Does the limp go away after you walk a short distance or does it
Functional Assessment
Ask specifically about activities of daily living. First, ask the general category; then, if a positive response
is elicited, inquire about each activity in the category. Does your joint or muscle problem cause
problems with:
Bathing: Getting in and out of the tub, turning the faucets?
Toileting: Urinating, having a bowel movement, getting on or off the toilet without assistance, cleaning
or wiping yourself?
Dressing: Fastening buttons, zipping a zipper, fastening a necklace or button behind your neck, pulling
your dress or sweater over your head, pulling up your pants, putting on your socks, tying your shoes,
finding shoes that fit comfortably?
Grooming: Shaving, brushing hair or fixing hair, brushing teeth, applying makeup?
Eating: Preparing food or meals, pouring liquids, cutting up foods, getting the food to your mouth,
Mobility: Walking, walking up or down stairs, getting in or out of beds, getting out of the house?
Communicating: Talking, using the phone, writing, using the computer?
Ask the patient about his or her self-care activities. Does the patient follow an exercise routine? What is
the program and how often is it followed (length of time and number of days per week)? Does his or her
job involve lifting or repetitive motions? Has the patient tried anything to improve the work station and
alleviate stressors?
If you have not already asked, inquire about medications, both prescription and OTC. If antiinflammatory drugs are used, ask about gastrointestinal upset or irritation from the medications.
Inquire about self-esteem concerns. Chronic pain and/or disability can lead to depression and selfisolation.
Infants and Children
Did your baby experience any trauma during labor and delivery that you are aware of? Were forceps
used to deliver the infant? Was the baby born headfirst at delivery? Difficult or traumatic deliveries can
result in fractures, such as clavicular or humeral fractures.
Did the infant require extra care immediately after birth, such as resuscitation or oxygen? Anoxic injury
can cause hypotonia of the muscles. If cardiac compressions were required, rib cage injuries may be
Did your baby achieve the suggested motor skill milestones as your other children or as compared to
national standards? Did your pediatrician discuss these milestones with you?
Has your child had any broken bones, sprains, or dislocations? How were these injuries treated? Are
there any residual problems?
Have you noticed any bony deformities on your child? Where? How about curving of the spine or pants
that fit “unevenly”? Are the feet shaped “normally”? Have you sought treatment for these problems?
Has your child been screened for scoliosis?
Do or have you participated in sports at school? How often do you play? Do you have to have special
equipment to play? Tell me about the equipment. Do you have a training program for this sport?
How do you warm up before playing a sport? Do you have a “cool down” session?
What do you do if you get hurt? Have you been hurt before? What happened?
How do you fit in sports with your other school activities? Does playing sports affect your homework or
school grades?
The Older Adult
Use your functional assessment questions for the older adult. You should also ask about the following:
Have you experienced any change in weakness over the past six months or year?
Have you noticed any increase in falls or gait changes in the past 12 months?
Do you use a cane, walker, or rolling walker to help you get around?

Musculoskeletal History

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