Poor Concentration Watery nose Confusion Congested Headaches: Infection After Meals Polyps Severe Acute smell Migraine Drainage Frontal Sneezing spells Afternoon Post nasal drip Occipital No sense of smell Afternoon Do the change of seasons tend to make Daytime your symptoms worse? Yes/No Relieved by: If yes, is it worse in the: Eating Sweets Spring Concussion/Whiplash Summer Mental sluggishness Fall Forgetfulness Winter Indecisive Face twitch Poor memory MOUTH: Hair loss Coated tongue Sore tongue Teeth problems EYES: Bleeding gums Feeling of sand in eyes Canker sores Double vision TMJ Blurred vision Cracked lips/ corners Poor night vision Chapped lips See bright flashes Fever blisters Halo around lights Wear dentures Eye pains Grind teeth when sleeping Dark circles under eyes Bad breath Strong light irritates Dry mouth Cataracts Floaters in eyes Visual hallucinations THROAT: Mucus Difficulty swallowing EARS: Frequent hoarseness Aches Tonsillitis Discharge/Conjunctivitis Enlarged glands Pains Constant clearing of throat Ringing Throat closes up Deafness/Hearing loss Itching NECK: Pressure Hearing aid Stiffness Frequent infections Swelling Tubes in ears Lumps Sensitive to loud noises Neck glands swell Hearing hallucinations NOSE/SINUSES CIRCULATION/RESPIRATION: Stuffy Swollen ankles Bleeding Sensitive to hot Running/Discharge
Poor Concentration Confusion Headaches: After Meals Severe Migraine Frontal Afternoon Occipital Afternoon Daytime Relieved by: Eating Sweets Concussion/Whiplash Mental sluggishness Forgetfulness Indecisive Face twitch Poor memory Hair loss EYES: Feeling of sand in eyes Double vision Blurred vision Poor night vision See bright flashes Halo around lights Eye pains Dark circles under eyes Strong light irritates Cataracts Floaters in eyes Visual hallucinations EARS: Aches Discharge/Conjunctivitis Pains Ringing Deafness/Hearing loss Itching Pressure Hearing aid Frequent infections Tubes in ears Sensitive to loud noises Hearing hallucinations NOSE/SINUSES Stuffy Bleeding Running/Discharge Watery nose Congested Infection Polyps Acute smell Drainage Sneezing spells Post nasal drip No sense of smell Do the change of seasons tend to make your symptoms worse? Yes/No If yes, is it worse in the: Spring Summer Fall Winter MOUTH: Coated tongue Sore tongue Teeth problems Bleeding gums Canker sores TMJ Cracked lips/ corners Chapped lips Fever blisters Wear dentures Grind teeth when sleeping Bad breath Dry mouth THROAT: Mucus Difficulty swallowing Frequent hoarseness Tonsillitis Enlarged glands Constant clearing of throat Throat closes up NECK: Stiffness Swelling Lumps Neck glands swell CIRCULATION/RESPIRATION: Swollen ankles Sensitive to hot
Health-History-Form-patient-1.docx