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  • robinapark

Clinical history and work up

Updated: Feb 6, 2021

Demographic data:

Name, Age, Location

Referral source:

GP/Specialist/Follow on


Summary and Formulation:

An introductory statement of salient demographic data. A brief summary of the most important features of history and examination. Diagnoses.

- Predisposing - Precipitating - Perpetuating - Aggravating

- Relieving factors

Sophisticated formulations illustrate

  • How influential are these factors?

  • How do they relate to the disease, suffering and function of the patient

  • What are the dynamic interaction of the biological, psychological and social components of the case (e.g. what psych things may stop them doing therapy)

  • How may these things affect long term outcomes

Management plan (immediate, short and long term)

- Non-professional influences / care providers (e.g. family)

- Involvement of allied health

- Pharmacological and medical follow up including referrals

- Procedures recommended

- Consider limitations in management (e.g. medication unavailable)

- Follow up planning


Presenting complaint:

History of presenting complaint:

(LINDOCARRF - remember intensity at rest and activity)

Impact of pain on life: (ADLs, Social)

Current and past pain treatments: (Pharmacological, interventional, psychological/allied health, complementary, OTC)

Occupational impact and history: (Including legal/claims, past jobs, current financial income etc).

PMHx/PSHx (other):

Medications (Analgesia):

Medications (Other):


Family history: (If relevant)

Social history: (HEADSS) (don't forget substances)

Psychological history:

- Formal diagnoses

- Supportive factors (Coping, Self efficacy, Locus of control)

- Maladaptive factors (Catastrophising, Fear avoidance)

- Suicidal screen

Forensic history: (if relevant)


  • Physical – pain orientated, functional and other relevant

  • Mental state


  • Positive and negative, past and pending or to be ordered

Diagnostic List (with Taxonomy Framework) - (IASP, DSM 5, ICD-11)


Terminology to utilise:

High external or internal - Locus of control:

Pain generator:

Coping strategies:


Adaptive and maladaptive strategies:

Fear-avoidance behaviours:

Passive versus active treatments:

Social withdrawal:

Uses aids and displays pain:

Negative cognitions: (High external locus of control)

Positive cognitions: (Divert, self 'talk', ignore)



2-1-3 - Discuss the application of the World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) concepts to people experiencing pain.

2-1-10 - Adapt assessment techniques to vulnerable populations, including but not limited to: 􏰀- Children - Older persons

- Persons with cognitive, behavioural, mobility or communication impairments


2-1-16 - Describe the differences between active and passive modalities of therapy.

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