History (Medical, Social, Psychological)
Historical material regarding the examinee’s injury or medical event, acute treatment, subsequent treatment, developmental milestones, medical status, vocational history, education background, and other foundational material against which test results are evaluated.
When obtaining background information from an individual being examined, clinicians will often choose to review available materials documenting the patient’s accident, medical treatment, educational records, employment history, mental health treatment, and other historical information. The information is obtained through a face-to-face clinical interview as well as from a review of existing documented records. The written materials may provide an objective reporting of the information. The interview may provide a subjective reporting. However, subjectively recalled information from the patient alone might fail to provide a complete or accurate history.
One use of...