To help us better evaluate your condition, please complete the following form. If you have any questions we will be glad to help you. Thank you.
Date of Injury:
Weight loss or gainFatigueFever or chillsWeaknessTrouble sleeping
RashesLumpsItchingDrynessColor changesHair and nail changesAbnormal skin lesions
HeadacheHistory of traumatic brain injuryHistory of concussion
Decreased hearingRinging in earsEaracheDrainage
Use of glasses or contactsVision loss/changesPainRednessBlurry or double visionFlashing lightsFloating specksGlaucomaCataractsYour last eye exam
StuffinessDischargeItchingHay feverNosebleedsSinus pain
BleedingDenturesSore tongueDry mouthSore throatHoarsenessThrushNon-healing sores
CoughSputumCoughing up bloodShortness of breathWheezingPainful breathingSleep apnea
Chest pain or discomfortTightnessPalpitationsDifficulty breathing lying downSwellingHistory of heart attack, date ____Pacemaker
Swallowing difficultiesHeart burnChange in appetiteNauseaRectal bleedingConstipationDiarrhea
FrequencyUrgencyBurning or painBlood in urineIncontinence
Leg crampingCalf pain with walking
Muscle or joint painStiffnessBack painRedness of jointsSwelling of joints
DizzinessFaintingSeizuresWeaknessNumbnessTinglingTremorsHistory of stroke, date: ____
Ease of bruisingEase of bleedingKnown coagulation disorderTaking an anticoagulant such asWarfarin, Coumadin, Xarelto
Heat or cold intoleranceSweatingFrequent urinationThirstChange in appetite
NAME OF MEDICATION
TYPE OF SURGERY
TYPE OF INJURY
Is there anything else regarding your health that we should know when treating you?
The above is accurate to the best of my knowledge.