What is the reason for your visit?

Angry
Depressed
Disgust
Embarassed
Envy
Frustrated
Guilty
Happy
Humiliated
Lonely
Neutral
Outraged
Rejected
Sad
Scared
Shameful
Shocked
Stressful
 

How long have you felt this way?

 
 

Do you have any of these symptoms?

GENERAL SYMPTOMS

Difficulty sleeping
Fatigue / weakness
Fever
Loss of appetite
Mood changes
Night sweats
Weight loss / gain

HEAD / NECK

Congestion / sinus problem
Difficulty / pain swallowing
Ear drainage
Ear pain
Eye redness / discharge
Headache
Hearing loss / ringing
Nasal discharge
Nose bleeds
Sore throat

CHEST

Chest pressure / pain
Cough
Decreased excercise tolerance
Shortness of breath
Sputum / productive cough / phlegm

GASTROINTESTINAL

Wheezing
Abdominal pain / discomfort
Blood in stool
Constipation
Diarrhea
Heartburn / reflux

GENITOURINARY

Nausea / vomiting
Blood in urine
Discomfort / burning with urination
Frequent urination
Penile discharge
Testicular pain

NEUROLOGICAL

Testicular swelling
Dizzy / lightheaded
Loss of consciousness
Memory loss
Numbness / tingling
Tremors

SKIN

Vision changes
Bites
Bleeding
Bruising / discoloration
Itching
Skin rashes / bumps
Scores

MUSCULOSKELETAL

Swelling
Back pain
Joint stiffness
Limited motion / mobility
Muscle pain
Muscle weakness
Swelling