UNIVERSIDAD PRIVADA DE TACNA

FACULTAD DE CIENCIAS DE LA SALUD

PHYSIOTHERAPEUTIC CLINICAL
HISTORY
ENGLISH

Teacher:
Guido

Students:
Xiomara Avalos Yufra
Piero Chambi Lupaca

Cycle:
5th

- TACNA 2019 -
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. 1

Health problem:
Clinical diagnosis:

Anamnesis:
Personal history:

Previous diseases: Other diseases:

Family pathology: some or some of your relatives have suffered
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:

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.

Exploration:
Physical exploration:
Weight:
Size:
Body Mass Index (BMI):
Ethnicity:
Complementary explorations:
Relevant findings:

Pharmacotherapy:
The patient has prescribed for the current problem
It self-medicates with
Other medication:

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.

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.

Diagnosis
Main diagnosis of Physiotherapy:.

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: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 HISTORY