Chiari Patient Questionnaire

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2022-CONT-Medical Center of Aurora-Chiari Patient Questionnaire-PHI
Name*
Address*
Date of Birth*
Which hand is dominant (typically the hand you write with)?

Chief Complaint

Have you ever had a head or neck injury?*

History of Present Illness

Do you have headaches?*
How would you describe the pain? (Mark all that apply)
Headaches are worse when (mark all that apply):

Check all symptoms that you may have experienced:

Constitutional
Eyes
Ear, Nose, Mouth, Throat
If you experience ringing in your ears, which ear is it?
If you experience a decrease or loss of hearing, in which ear?
If you have problems swallowing, which gives you the most difficulty?
Neurological
If you experience pain or numbness in your face, which side?
Psychiatric
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary
Peripheral Vascular
Endocrine
Hematologic/Lymphatic
Sleep