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Personal Information

Name *
E-Mail *
Referred By *
Reason *

What Are Your Symptoms? *
How Long Have You Had These Symptoms? *
What Treatment(s) Have You Received? *
Patient/Parent or Guardian Signature
Physician Signature
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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