Which office are you being treated in?* Toms River Freehold Name* First Last Today's Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email* Please list your current medicationsSYMPTOM CHECKLISTCheck all that applyPHYSICAL Headaches Backaches Sexual Problems Significant weight change Numbness/weakness on either side of body Heart pounding/racing Poor vision Sensitivity to light Sensitivity to noise Hearing impairment Tinnitus (ringing in the ears) Decrease/increase in appetite Change in taste Change in smell Loss of balance Poor coordination Nausea Sweating hands/feet Cold hands/feet Teeth grinding/clenching Pain If you are feeling pain, describe the location of the pain:COGNITIVE Forgetfulness Poor concentration Slowed thinking Difficulty managing daily activities Difficulty making decisions Changes in judgement Difficulty understanding what others say Language/speech difficulty If you are having language difficulty, explain:EMOTIONAL Changes in personality Feelings of depression Feelings of irritability Frequent racing thoughts Anxiety/fear/panic Feelings of unreality Nervousness/shakiness Decreased energy Fear of riding/driving in an automobile Flashbacks Thoughts of hurting yourself Thoughts of hurting others SLEEP Trouble falling asleep Nightmares Sleeping more than usual Sleeping less than usual SOCIAL Marital discord Problems with family/friends Problems in work performance Trouble participating in sports Academic difficulties Trouble participating in social settings CAPTCHA Δ
