History and examination

Abstract

This chapter describes the principles of taking a history, an essential part of a comprehensive assessment of an individual by a rehabilitation physician, including presenting complaints; assessment of body function, activities, and participation; past medical and functional history; review of symptoms; personal and environmental history; and the individual’s perception of their condition. The approach taken in eliciting a history in rehabilitation settings is unique in that there is equal emphasis on understanding the impact of any illness on body function, activities, and participation in the context of that particular individual in the unique environment they live in. Describing examination of the neurological system and musculoskeletal system, the chapter provides details of how to design a rehabilitation plan, and methods for successful implementation.