Presenting complaint
Clarify the principal symptom in the patient's own words and establish its duration and progression.
Pain
Record:
- site and radiation
- onset and duration
- character
- severity
- aggravating and relieving factors
- night pain
- rest pain
- mechanical symptoms
Functional effect
Ask specifically about:
- walking distance
- stairs
- work
- sport
- dressing and footwear
- sleep
- use of aids
- ability to perform activities important to the patient
Associated symptoms
- swelling
- stiffness
- instability or giving way
- locking or catching
- neurological symptoms
- fever or constitutional symptoms
Relevant background
- previous trauma or surgery
- previous treatment and response
- inflammatory disease
- diabetes, vascular disease or neurological disease
- infection risk
- medications including anticoagulants and steroids
- allergies
Social history
- occupation
- smoking
- alcohol
- home circumstances
- mobility aids
- driving
- support network
Final step
Summarise the history, identify red flags and establish the patient's expectations and treatment goals.