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Coshocton, OH
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Coshocton, OH (opens in new window)(opens in new window)(opens in new window)

112 Chestnut St, Coshocton, OH 43812

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General Medical History and Symptoms Form

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Patient First Name

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Patient Last Name

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N-1 Check if you experience the following symptoms:

Numbness in feet or hands

Prickly / tingly pain in the hands or feet

Sharp / Stabbing pain in feet

Cold Feet

Burning in Feet

Balance problems

Feet "hypersensitive" to touch

Cramping in feet

CPTM-1 Do you suffer from?

Headaches / Migraines

Neck Pain

Mid-back Pain

Low-back Pain

Sciatic Pain

Leg / Hip Pain

Shoulder / Arm Pain

Ankle / Foot Pain

Fibromyalgia

Stomach Problems

Wrist Pain

Elbow Pain

Knee Pain

Carpal Tunnel

L/D-1

Do you experience pain radiating past your knee

Do you experience pain radiating past your elbow

Have you had an MRI that has indicated a disc injury / bulging disc

C-1 Check if you experience the following symptoms:

Headaches

Difficulty with restraint / desire

Emotional instability

Difficulty planning / organizing

Difficulty making decisions

Lack of motivation (enthusiasm, interest)

Difficulty getting sound / melody out of your thoughts

Repeating events or thoughts with difficulty letting go

Difficulty beginning / finishing tasks

Depression

Mental fatigue

Decreased attention span

Difficulty concentrating for extended periods of time

Noticeable difference in muscle tightness from one side to the other

Noticeable difference in muscle function or strength from one side to the other

Reoccurring injury in the same body part or side of the body

Difficulty recalling words

Memory is less efficient

Forgetting where you put things

Anxiety

Do you get fatigued after meals

Do you get irritable between meals

General Medical History. Mark if any symptoms in the last 5 years:

Unexplained Fevers

Night sweats

Weight loss of 10 lbs or more

Loss of appetite

Excessive fatigue

Dark black stools

Unusual stress at work

Unusual stress at home

Easy bruising

Excessive bleeding

Sores & Wounds

Blood clots

Ulcers on Foot

Lumps in neck, armpit or groin

Persistent eye redness

Persistent or unusual cough

Trouble breathing with exercise

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