Required fields are marked with an asterisk *. First Name *Middle InitialLast Name *City *State *Date of Birth *Age *HeightWeightWhich hand is dominant (typically the hand you write with)? Right LeftChief ComplaintWhat symptom bothers you the most? *How long have you noticed this? *Have you ever had a head or neck injury? * Yes NoIf yes, please explain:History of Present IllnessDo you have headaches? * Yes NoHow long have you had headaches?Where in your head do you feel the pain?How long do your headaches last?How would you describe the pain? (Mark all that apply) Pressure Sharp Stabbing Throbbing Aching PoundingOther description of painHeadaches are worse when (mark all that apply): Coughing Sneezing Straining Laughing Singing Bending Forward Looking upOn a scale of 1 (very mild) to 10 (most severe), how would you rate your most severe headache? * 1 2 3 4 5 6 7 8 9 10Check all symptoms that you may have experienced.Constitutional Fatigue General Body Weakness Weight Loss Weight Gain FeverEyes Light Sensitivity Blurred Vision Double Vision Seeing Spots Loss of VisionIf you experience loss of vision, how often does this happen?If you experience loss of vision, please describe your experience below:Ear, Nose, Mouth, Throat Ringing in your ears Hearing Loss Hearing Aids Voice hoarseness Problems swallowing Nose Bleeds Seasonal AllergiesIf you experience ringing in your ears, which ear is it? Left Ear Right Ear Both EarsIf you experience a decrease or loss of hearing, in which ear? Left Ear Right Ear Both EarsIf you have problems swallowing, which gives you the most difficulty? Swallowing Liquids Swallowing Solids Swallowing BothNeurological Dizziness Vertigo (spinning) Face numbness Face pain Difficulty speaking Short-term memory issues Long-term memory issues Thinking errors Balance issues Seizures Blackout spellsIf you experience seizures or blackout spells, please explain below:If you experience pain or numbness in your face, which side? Left Side Right Side Both SidesPsychiatric Anxiety Depression Panic attacksCardiovascular Chest pain Palpitations (racing heart) Slow heart rateRespiratory Cough Shortness of breath Sleep apnea CPCP or Oxygen useGastrointestinal Poor appetite Nausea Vomiting Abdominal pain Indigestion Diarrhea ConstipationGenitourinary Problems starting urination Urgency to urinate Wake up to urinate Loss of bladder controlMusculoskeletal Neck pain Lower back pain Right arm pain Left arm pain Left arm numbness Right arm numbness Left arm tingling Right arm tingling Left arm weakness Right arm weakness Left leg weakness Right leg weakness Left leg pain Right leg pain Left leg numbness Right leg numbness Left leg tingling Right leg tingling Left leg cramps Right leg crampsIntegumentary Rash Skin lesions/sores Sore that don't heal Skin infectionPeripheral Vascular Leg/ankle swelling Varicose veinsEndocrine Thyroid problems Night chillsHematologic/Lymphatic Easy bruising Easy bleeding Swelling of lymph glandsSleep Snoring Poor sleep Stop breathing Daytime sleepinessPlease list any other symptoms not listed above.Please provide any comments on any of the symptoms listed above. Rate Your Experience Submit Your form has been securely transmitted to the Colorado Chiari Institute! There was an error with the form submission.