Differential Diagnosis in PT, P-02: Client History and Screening Interview (U)


Evidence-based clinical decision-making consistent with the patient/client management model will be the foundation upon which a physical therapy differential diagnosis is made. The physical therapy diagnosis begins with a screening component. In turn, screening for systemic disease begins with a well-developed client history and interview. The foundation for these skills is presented in this course.

The client interview, including the personal and family history, is the single most important tool in screening for systemic disease.

Restated for emphasis: The client interview as it is presented here is the first step in the screening process. Risk factor assessment and health screening are also included, as these are becoming a more integral part of the physical therapist’s practice in the primary care setting.

A large part of the screening process is identifying red flag histories and red flag signs and symptoms. Many clients are experiencing signs and symptoms associated with visceral impairment but don’t make the connection between these signs and symptoms and their NMS dysfunction. The therapist must be well-versed in what questions to ask in order to obtain this information.

Upon completion of this course, the Learner will be able to:
  • Recognize the importance of the client history in client management
  • Describe the role of the physical therapy interview in evaluations of all clients
  • Incorporate the Guide into the interview process
  • Recognize red flag signs, symptoms and history
  • Identify situations requiring medical referral
  • Determine what questions to ask to screen for assault and substance use/abuse
  • Describe the importance of vital sign assessment in the screening process