• Gain informed consent
  • 1. Explain the nature of the treatment, benefits, risks, side effects, alternative courses of action, and any possible consequences of not having the treatment
  • 2. Answer questions asked from patient
  • 3. Get consent verbally, in writing, or implied through behaviour
  • 4. Patients can refuse consent or withdraw consent at any moment 

5. If the patient is unable to consent secondary to their confusion, refer to the substitute decision maker.

• Subjective
  • When did the symptoms occur?
  • What symptoms were you experiencing?
  • Where were you feeling these symptoms?
  • How long did these symptoms persist/when do you feel these symptoms?
  • What is the characteristic of pain/symptoms? (ie. dull, sharp)
  • Do your symptoms limit your activities of daily living?
  • Have you had a diagnosis?
  • Has this happened before?
  • Have you been treated for this issue before?
  • Do you have a cough?
    • How long has this been prevalent?
    • Do you normally have a cough?
  • How much sputum/phlegm do you “spit out”
    • Is this normal?
    • Can you get out the sputum/phlegm yourself?
    • What colour is it typically?
  • Do you normally experience breathlessness?
    • How long does it take before you become breathless typically?
    • Does it normally limit you?

• Past medical history?
  • Any recent surgeries?
  • Any use of ventilation devices before?
  • Family history?
  • Any other comorbidities?
  • Any allergies?
  • Have you been immunized?
    • Pneumonia
    • Influenza 
    • COVID-19
  • Have you had any other recent investigations?
  • Any trauma?
  • Medications?
• General Health
  • Do you smoke?
  • What is your alcohol intake?
  • What is your physical activity level?
  • How is your sleep?

• Social history?
  • How is their living situation?
  • Are they living with anyone at home?
  • Are there stairs in the house?
  • Is the bedroom and bathroom on the main floor?
  • If there is someone at home with them, are they in good health?
  • Are they driving?
  • How is transportation? 
  • Any hobbies?
  • What is their job/occupation?
• Goals
  • What do they want to achieve from physiotherapy?
  • Collaborate with patient on short and long term goals