[Ask The Doctor]
We will now lead you through a questionaire that will help us greatly determine your past history and current medical problems you may have. There are 12 pages but the information we gather from this is very important in doing a correct diagnosis. Items in RED are required.
Basic Patient Information
Name:
E-Mail:
Age:

SECTION I (Musculoskeletal)

Please use the following numbers to represent your experience with the following list of symptoms:

1- Presently have. 4- Not having now but repeatedly bothered by.
2- Have had in the past 2 years but not now. 5- Not me but other family members.
3- Have had, but no symptoms in the past 2 years. Leave blank if none apply.
Arthritis (16) Lupus Erythematosus (120)
Body Aches (22) Muscle Spasm (132)
Bone and Joint Pain (24) Myofascial Pain (197)
Bursitis (298) Osteoarthritis (239)
Chewing Disturbance (207) Osteomyelitis (144)
Exostosis (67) Osteoporosis (145)
Extremity Joint Pain (68) Periarthritis (149)
Fractures (77) Periostitis (152)
Gout (85) Radicular & Joint Pain (162)
Headaches (88) Rheumatoid Arthritis (164)
Inflammations (103) Shingles (168)
Intercostal Neuralgia (107) Sprains (172)
Jaw Ache (233) Stiffness (174)
Ligament Damage (234) Subluxations (180)