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Home
About Us
Our Facility
Meet Our Team
Treatment Areas
Back Pain
Neck Pain and Headaches
Shoulder Pain
Elbow Pain
Wrist/Hand Pain
Hip Pain
Knee Pain
Sports Injuries
Fibromyalgia
Specialties
Medication Management
Interventional Pain Procedures
Medical Weight Loss
Sleep Management
For Patients
Patient Forms
Blog
Lectures
Videos
Testimonials
Physicians
Referrals
Education and Training
Contact Us
Patient health questionaire Form
Patient health questionaire Form
Zahid Ramzan
2022-10-21T23:03:39+00:00
Patient Health Questionnaire
Please mark all conditions which you currently have.
Constitutional Symptoms
Fever
Chills
Fatigue
Nutritional Assessment
Weight loss
Weight gain
Poor appetite
Respiratory
Painful breathing
Productive cough
Emphysema
COPD
TB
Asthma
Cardiovascular
High blood pressure
Chest pain
Heart attack
Abnormal heart rhythm
Swelling of ankles
Pacemaker/ AICD
Blood clot
Use of blood thinners
Mitral Valve Prolapse
Gastrointestinal
Abdominal pain
Heartburn
Hiatal hernia
Ulcers
Liver Problems
Gallbladder problems
Hepatitis
Bloody Stools
Diarrhea
Constipation
Loss of bowel control or incontinence
Genitourinary
Painful urination
Bladder infection
Difficult urination
Recent frequent urination
Blood in urine
Kidney Disease
Kidney Failure
STD
Recent urinary retention
Incontinence
Musculoskeletal
Arthritis
Swollen joints
Muscle pain
Fall or accident
Major motor weakness
Integumentary (skin or breast)
Rash
Itching
Bruise easily
Shingles
Skin cancer
Neurological
Headache
Multiple sclerosis
Seizure
Head injury
Stroke
Tremors
Weakness
Tingling
Numbness
Dizziness
Loss of coordination
Psychiatric
Alzheimer’s
Depression
Anxiety
Panic attacks
Alcoholism
Thoughts of suicide
Irritability
Endocrine
Thyroid disease
Diabetes
Hematologic/ Lymphatic
Leukemia
Lymphoma
Bleeding disorder
Swollen glands
Hepatitis
Immunologic
AIDS
HIV
Cancer
Family Health History
Mother
Father
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