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1099 Florida Avenue

Rockledge, FL 32955 US

(321) 632-6900

(321) 639-7222

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Name *

 

E-Mail *

 

Referred By *

 

Reason *

 

What Are Your Symptoms? *

 

How Long Have You Had These Symptoms? *

 

What Treatment(s) Have You Received? *

 

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Date

 

Date

 

Are You Currently Or Do You Regularly Experience: *

Please check yes or no. Do not leave any item blank.
 
Constitutional
 
Weight Loss Yes No Fatigue Yes No
Fever Yes No    
 
       
Eyes
 
Blurred Vision Yes No Double Vision Yes No
Eye Pain Yes No    
 
       
Ears
 
Ringing in Ears Yes No Vertigo/Dizziness Yes No
Hearing Loss Yes No Ear Pain Yes No
Itching In Ear Yes No Roaring Sound Yes No
Ear Discharge Yes No Ear Fullness Yes No
Pressure Sensation Yes No    
 
       
Nose
 
Nasal Obstruction Yes No Nasal Pain Yes No
Decreased Sense of Smell Yes No Nose Bleeding Yes No
Nasal Discharge Yes No Postnasal Drip Yes No
Nasal Congestion Yes No Snoring Yes No
 
       
Throat, Mouth & Sinus
 
Sore Throat Yes No Swollen Glands Yes No
Difficulty Swallowing Yes No Change In Voice Yes No
Hoarseness Yes No Lump In Throat Sensation Yes No
Neck Tenderness Yes No Mouth Pain Yes No
Frequently Throat Clearing Yes No Dentures Yes No
Sinus Pain Yes No Headaches Yes No
 
       
Cardiovascular
 
Chest Pain Yes No Palpitations Yes No
High Blood Pressure Yes No    
 
       
Respiratory (Lungs)
 
Shortness of Breath Yes No Wheezing Yes No
Cough Yes No Coughing Blood Yes No
 
       
Gastrointestinal (Stomach)
 
Nausea Yes No Vomiting Yes No
Difficulty Swallowing Yes No Painful Swallowing Yes No
Excessive Belching Yes No Heartburn/Acid Reflux Yes No
 
       
Genitourinary
 
Urgency Yes No Frequency Yes No
Pain When Urinating Yes No    
 
       
Integumentary (Skin)
 
New Skin Lesions Yes No Pigmentation Changes Yes No
Changes to Existing Lesions Yes No    
 
       
Neurological (Nerves)
 
Tremors Yes No Seizures Yes No
Loss of Balance Yes No Tingling or Numbness Yes No
 
       
Musculoskeletal
 
Joint Pain Yes No Joint Swelling Yes No
Muscle Pain Yes No    
 
       
Endocrine
 
Cold Intolerance Yes No Heat Intolerance Yes No
Loss of Hair Yes No Weight Loss Yes No
Weight Gain Yes No Hot Flashes Yes No
 
       
Psychiatric
 
Anxiety Yes No Depression Yes No
Difficulty Sleeping Yes No    
 
       
Hematologic/Lymph Nodes
 
Easy Bleeding Yes No Easy Bruising Yes No
Enlargement or Tenderness Yes No    
 
       
Allergic/Immunologic
 
Reaction to Anesthesia Yes No Sneezing Yes No
Itchy Watery Burning Eyes Yes No    
 

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