CLIENT SYMPTOM QUESTIONNAIRE Patient’s Name: Email Address: Mobile Number: Is this related to an auto accident or work injury? Auto AccidentWork Injury Incident Date: Today’s Date: PLEASE CHECK ALL THAT APPLY: Head NECK PAINHEADACHESFACE PAINDIZZINESSDIFFICULTY WALKINGBALANCE PROBLEMSDISORIENTED/ROOM SPINSCONFUSEDDAYDREAMINGATTENTION ISSUESHEARING ISSUESCHANGE IN SENSE OF SMELL/TASTEDIFFICULTY SPEAKINGMEMORY LOSSTIRED OR FATIGUEDAPPETITE CHANGEDIFFICULTY SLEEPINGVISUAL DISTURBANCESBLURRED VISIONFLASHBACKS TO ACCIDENTPROBLEMS READING OR WRITINGPROBLEMS UNDERSTANDINGPROBLEMS UNDERSTANDINGPROBLEMS REMEMBERING #sDIFFICULTY CONCENTRATINGDIFFICULTY MAKING DECISIONSCHANGE IN SEXUAL FUNCTIONNAUSEA/VOMITINGWANTING TO BE ALONEMOOD SWINGSSADNESSAGITATION Neck NECK PAIN, NUMBNESS, TINGLING, AND/OR WEAKNESS THAT RADIATES OR GOES DOWN TO RIGHT/LEFT SHOULDER, ARM, FOREARM, ARM, OR UPPER BACKNECK PAIN THAT CAUSES HEADACHESNECK OR SHOULDER SPASMSNECK PAIN THAT CAUSES HEADACHESPOPPING OR CLICKING SOUND Back UPPER, MID, OR LOW BACK PAINBACK SPASMSBACK PAIN, NUMBNESS, TINGLING, AND/OR WEAKNESS THAT RADIATES OR GOES TO RIGHT/LEFT SHOULDER, ARM, FOREARM, HAND, BUTTOCK, THIGH, LEG, OR FOOT OTHER SYMPTOMS:
