Name .. ..Date of birth
Tel No ...Todays Date
1.Describe your symptom as accurately as you can.
2. When exactly did it start?
3.Is it there all the time?
4.Does anything bring it on or make it worse?
5.Does anything make it easier?
6.Are your sight or hearing affected?
7.Do you lose consciousness or faint?
8.Please list any tablets or treatments you are taking, including those not actually prescribed by a doctor.
9.Are you more depressed or worried than usual?
10.Is there anything in your lifestyle which could be contributing to the problem?
11. Do you know of anyone who has a similar problem?
12. Could you express any opinions or secret fears that may have crossed your mind or been suggested as to the cause of the pain.
13.please describe any other symptoms.
14. Is there anything else I should know?
Temperature . BP .Pulse ..
Neck movements ..
Ear Drums .Rinnee Weber .
Diagnosis and Plans: