PATIENT SYMPTOMS FORM

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404.631.6156

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Is this related to an auto accident or work injury?*

Auto Accident

Option Work Injury

Incident Date*

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Month

Day

Year

HEAD

NECK PAIN

HEADACHES

FACE PAIN

DIZZINESS

DIFFICULTY WALKING

BALANCE PROBLEMS

DISORIENTED/ROOM SPINS

CONFUSED

DAYDREAMING

ATTENTION ISSUES

HEARING ISSUES

CHANGE IN SENSE OF SMELL/TASTE

DIFFICULTY SPEAKING

MEMORY LOSS

TIRED OR FATIGUED

APPETITE CHANGE

DIFFICULTY SLEEPING

VISUAL DISTURBANCES

BLURRED VISION

FLASHBACKS TO ACCIDENT

PROBLEMS READING OR WRITING

PROBLEMS UNDERSTANDING

PROBLEMS REMEMBERING #s

DIFFICULTY CONCENTRATING

DIFFICULTY MAKING DECISIONS

CHANGE IN SEXUAL FUNCTION

NAUSEA/VOMITING

WANTING TO BE ALONE

MOOD SWINGS

SADNESS

AGITATION

Neck

NECK PAIN, NUMBNESS, TINGLING, AND/OR WEAKNESS THAT RADIATES OR GOES DOWN TO RIGHT/LEFT SHOULDER, ARM, FOREARM, ARM, OR UPPER BACK

BACK

NECK PAIN THAT CAUSES HEADACHES

NECK OR SHOULDER SPASMS

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