Add Complaint
List of Health Care Providers:
List the name, area of specialty, and address of all healthcare providers that are currently taking care of you. This should include, but is not limited to, primary care Physician, ENT, Neurologist, Rheumatologist, Dentist, Chiropractor, Physical Therapist, Acupuncturist, Nutritionist, Psychiatrist, Psychologist, Massage Therapist, etc.
Additional Healthcare Providers
Additional Factors
List all health care providers that you have seen for your present condition. Include their area of specialty, treatment provided, effectiveness of treatment, and date of treatment: (effectiveness scale 0-3 where 0=not effective and 3=very effective)
Add new row
Circulatory
Ear Nose Throat
In recent months have the headaches:
Muscle Aches
Add additional Muscle Ache
Numbness or diminished sensation in:
Oral / Facial:
Nasopharyngeal (nose/throat):
EAR:
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