Common Questions to Ask the Patient
Opening of the encounter:
“Mr. Jones, hello; I am your Acupuncturist Mike.
It’s nice to meet you. I’d like to ask you some questions and examine you today.”
“How can I help you today?”
“What brought you to the hospital or clinic today?”
“What made you come in today?”
Pain:
“Do you have pain?”
“When did it start?”
“How long have you had this pain?”
“How long does it last?”
“How often does it come on?”
“Where do you feel the pain?”
“Can you show me exactly where it is?”
“Does the pain travel anywhere?”
“What is the pain like?”
“Can you describe it for me?”
“Is it sharp, dull, burning, pulsating, cramping, or pressure-like?”
“Is it constant, or does it come and go?”
Numerical Pain Rating Scale (NPRS).
[ask the patient to rate their pain on average over the last
24 hours on a scale of 0-10, with ‘0’ being ‘no pain’
and ‘10’ being the ‘worst possible pain’.]
Patient Specific Functional Scale (PSFS).
[ask the patient to identify 3 important activities that they are
unable to do or are having difficulty with as a result of the
presenting problem and to score them according to the following
scale].
“On a scale of 1 to 10, with 10 being the worst pain of your life, how would you rate your pain?”
“What brings the pain on?”
“Do you know what causes the pain to start?”
“Does anything make the pain better?”
“Does anything make it worse?”
“Have you had similar pain before?”
Nausea:
“Do you feel nauseated?”
“Do you feel sick to your stomach?”
Vomiting:
“Did you vomit?”
“Did you throw up?”
“What color was the vomit?”
“Did you see any blood in it?”
Cough:
“Do you have a cough?”
“When did it start?”
“How often do you cough?”
“Do you bring up any phlegm with your cough, or is it dry?”
“Does anything come up when you cough?”
“What color is it?”
“Is there any blood in it?”
“Can you estimate the amount of the phlegm? A teaspoon? A tablespoon? A cupful?”
“Does anything make it better?”
“Does anything make it worse?”
Headache:
“Do you get headaches?”
“Tell me about your headaches.”
“Tell me what happens before or during or after your headaches.”
“When do your headaches start?”
“How often do you get them?”
“When your headache starts, how long does it last?”
“Can you show me exactly where you feel the headache?”
“What causes the headache to start?”
“Do you have headaches at certain times of the day?”
“Do your headaches wake you up at night?”
“What makes the headache worse?”
“What makes it better?”
“Can you describe the headache for me, please? Is it sharp, dull, pulsating, pounding, or pressure-like?”
“Do you notice any change in your vision before or during or after the headaches?”
“Do you notice any numbness or weakness before or during or after the headaches?”
“Do you feel nauseated? Do you vomit?”
“Do you notice any fever or stiff neck with your headaches?”
Fever:
“Do you have a fever?”
“Do you have chills?”
“Do you have night sweats?”
“Do you sweat during the night?”
“How high is your fever?”
Shortness of breath:
“Do you get short of breath?”
“Do you get short of breath when you’re climbing stairs?”
“How many steps can you climb before you get short of breath?”
“When did it start?”
“When do you feel short of breath?”
“What makes it worse?”
“What makes it better?”
“Do you wake up at night short of breath?”
“Do you have to prop yourself up on pillows to sleep at night? How many pillows?”
“Have you been wheezing?”
“How far do you walk on level ground before you have shortness of breath?”
“Have you noticed any fluid retention around your ankles?”
Urinary symptoms:
“Has there been any change in your urinary habits?”
“Do you have any pain or burning during urination?”
“Have you noticed any change in the color of your urine?”
“How often do you have to urinate?”
“Do you have to wake up at night to urinate?”
“Do you have any difficulty urinating?”
“Do you feel that you haven’t completely emptied your bladder after urination?”
“Do you need to strain or push during urination?”
“Have you noticed any weakness in your stream? Any dribbling of urine?”
“Have you noticed any blood in your urine?”
“Do you feel as though you need to urinate but then very little urine comes out?”
“Do you feel as though you have to urinate all the time?”
“Do you feel as though you have very little time to make it to the bathroom once you feel the urge to urinate?”
Bowel symptoms:
“Has there been any change in your bowel movements?”
“Do you have diarrhea?”
“Are you constipated?”
“How long have you had diarrhea or constipation?”
“How many bowel movements do you have per day or week?”
“What does your stool look like?”
“What color is your stool?”
“Is there any mucus or blood in it?”
“Do you feel any pain when you have a bowel movement?”
“Did you travel recently?”
“Do you feel as though you strain to go to the bathroom and then very little feces or none at all comes out?”
“Have you lost control of your bowels?”
“Do you feel as though you have very little time to make it to the bathroom once you have the urge to have a bowel movement?”
Weight:
“Have you noticed any change in your weight?”
“How many pounds did you gain or lose?”
“Over what period of time did it happen?”
“Was the weight gain or loss intentional?”
Appetite:
“How is your appetite?”
“Has there been any change in your appetite?”
Diet:
“Has there been any change in your eating habits?”
“What do you usually eat?”
“Did you eat anything unusual lately?”
“What did you eat before the symptoms started?”
“Is there any kind of special diet that you are following?”
Sleep:
“Do you have any problems falling asleep?”
“Do you have any problems staying asleep?”
“Do you have any problems waking up?”
“Do you feel refreshed when you wake up?”
“Do you snore?”
“Do you feel sleepy during the day?”
“How many hours do you sleep?”
“Do you take any pills to help you go to sleep?”
Dizziness:
“Do you ever feel dizzy?”
“Tell me exactly what you mean by dizziness.”
“Did you feel the room spinning around you, or did you feel light-headed as if you were going to pass out?”
“Did you black out?”
“Did you lose consciousness?”
“Did you notice any change in your hearing?”
“Do your ears ring?”
“Do you feel nauseated? Do you vomit?”
“What causes this dizziness to happen?”
“What makes you feel better?”
Joint pain:
“Do you have pain in any of your joints?”
“Have you noticed any rash with your joint pain?”
“Is there any redness or swelling of the joint?”
Travel history:
“Have you traveled recently?”
Past medical history:
“Have you had this problem or anything similar before?”
“Have you had any other major illnesses before?”
“Do you have any other medical problems?”
“Have you been hospitalized before?”
“Have you had any surgeries before?”
“Have you had any accidents or injuries before?”
“Are you taking any medications?”
“Are you taking any over-the-counter drugs, vitamins, or herbs?”
“Do you have any allergies?”
Family history:
“Does anyone in your family have the same problem or anything similar?”
“Are your parents alive?”
“Are they in good health?”
“What did your mother or father die of?”
“Are your brothers or sisters alive?”
“Are they in good health?”
Social history:
“Do you smoke?”
“How many packs a day?”
“How long have you smoked?”
“Do you drink alcohol?”
“What do you drink?”
“How much do you drink per week?”
“Do you use any recreational drugs such as marijuana or cocaine?”
“Which ones do you use?”
“How often do you use them?”
“Do you smoke or inject them?”
“What type of work do you do?”
“Where do you live? With whom?”
“Tell me about your life at home.”
“Are you married?”
“Do you have children?”
“Do you have a lot of stressful situations on your job?”
“Are you exposed to environmental hazards on your job?”
Alcohol history:
“How much alcohol do you drink?”
“Tell me about your use of alcohol.”
“Have you ever had a drinking problem?”
“When was your last drink?”
Administer the cage questionnaire:
“Have you ever felt a need to cut down on drinking?”
“Have you ever felt annoyed by criticism of your drinking?”
“Have you ever had guilty feelings about drinking?”
“Have you ever had a drink first thing in the morning (‘eye opener’) to steady your nerves or get rid of a hangover?”
Sexual history:
“I would like to ask you some questions about your sexual health and practice.”
“Are you sexually active?”
“Do you use condoms? Always? Other contraceptives?”
“Are you sexually active? With men, women, or both?”
“Tell me about your sexual partner or partners.”
“How many sexual partners have you had in the past year?”
“Do you currently have one partner or more than one?”
“Have you ever had a sexually transmitted disease?”
“Do you have any problems with sexual function?”
“Do you have any problems with erections?”
“Do you use any contraception?”
“Have you ever been tested for HIV?”
Gynecologic or obstetric history:
“At what age did you have your first menstrual period?”
“How often do you get your menstrual period?”
“How long does it last?”
“When was the first day of your last menstrual period?”
“Have you noticed any change in your periods?”
“Do you have cramps?”
“How many pads or tampons do you use per day?”
“Have you noticed any spotting between periods?”
“Have you ever been pregnant?”
“How many times?”
“How many children do you have?”
“Have you ever had a miscarriage or an abortion?”
“In what trimester?”
“Do you have pain during intercourse?”
“Do you have any vaginal discharge?”
“Do you have any problems controlling your bladder?”
“Have you had a Pap smear before?”
Pediatric history:
“Was your pregnancy full term (40 weeks or 9 months)?”
“Did you have routine checkups during your pregnancy? How often?”
“Did you have any complications during your pregnancy or during your delivery or after delivery?”
“Was an ultrasound performed during your pregnancy?”
“Did you smoke, drink, or use drugs during your pregnancy?”
“Was it a vaginal delivery or a C-section?”
“Did your child have any medical problems after birth?”
“When did your child have his first bowel movement?”
Growth and development:
“When did your child first smile?”
“When did your child first sit up?”
“When did your child start crawling?”
“When did your child start talking?”
“When did your child start walking?”
“When did your child learn to dress himself?”
“When did your child learn to tie his shoes?”
“When did your child start using short sentences?”
“When did your child start putting things in his mouth?”
Feeding history:
“Did you breast-feed your child?”
“When did your child start eating solid food?”
“How is your child’s appetite?”
“Does your child have any allergies?”
“Is your child’s formula fortified with iron?”
“Are you giving your child pediatric multivitamins?”
Routine care:
“Are your child’s immunizations up to date?”
“When was the date of your child’s last routine checkup?”
“Has your child had any serious illnesses?”
“Is your child taking any medications?”
“Has your child ever been hospitalized?”
Psychiatric history:
“Tell me about yourself and your future goals.”
“How long have you been feeling unhappy or sad or anxious or confused?”
“Do you have any idea what might be causing this?”
“Would you like to share with me what made you feel this way?”
“Do you have any friends or family members you can talk to?”
“Has your appetite changed lately?”
“Has your weight changed recently?”
“Tell me how you spend your time or day.”
“Do you have any problems falling asleep or staying asleep or waking up?”
“Has there been any change in your sleeping habits lately?”
“What interests or hobbies do you have? Do you enjoy them?”
“Do you take interest or pleasure in your daily activities?”
“Do you have any memory problems?”
“Do you have difficulty concentrating?”
“Do you have hope for the future?”
“Have you ever thought about hurting yourself or ending your life?”
“Do you think of killing yourself or putting an end to your own life?”
“Do you have a plan to end your life?”
“Would you mind telling me about it?”
“Do you feel that you want to hurt other people? Have you ever done so?”
“Do you ever see or hear things that others can’t see or hear?”
“Do you hold beliefs about yourself or the world that other people would find odd?”
“Do you feel as if other people are trying to harm or control you?”
“Has anyone in your family ever experienced depression?”
“Has anyone in your family ever been diagnosed with a mental illness?”
“Would you like to meet with a counselor to help you with your problem?”
“Would you like to join a support group?”
“What do you think makes you feel this way?”
“Can you tell me more about it?”
“Have you lost any interest in your social activities and relationships?”
“Do you feel hopeless?”
“Do you feel guilty about anything?”
“How is your energy level?”
“Can you still perform your daily functions or activities?”
“Do you have any thoughts of harming yourself?”
“Do you have any thoughts of harming others?”
“Whom do you live with?”
“How do they react to your behavior?”
“Do you have any problems in your job?”
“How is your performance on your job?”
“Have you had any recent emotional or financial problems?”
“Have you had any recent traumatic event in your family?”
“Does anyone support you?”
Daily activities (for dementia patients):.
“Tell me about your day yesterday.”
“Do you need any help bathing?”
“Do you need any help getting dressed?”
“What do you need help with when you are getting dressed?”
“Do you need any help going to the toilet?”
“Do you need any help transferring from your bed to the chair?”
“Do you ever have accidents with your urine or bowel movements?”
“Do you ever not make it to the toilet on time?”
“Do you need any help feeding yourself?”
“What do you need help with when you eat?”
“Do you need any help taking your medications or using the telephone or shopping or preparing food or cleaning your house or doing laundry or getting from place to place or managing money?”
Abuse:
“Are you safe at home?”
“Is there any threat to your personal safety at home or anywhere else?”
“Does anyone treat you in a way that hurts you or threatens to hurt you?”
“Can you tell me about the bruises on your arm?”