CURRENT SYMPTOMS LIFESTYLE AND HEALTH

PRACTICES
1. Do you have headache,
Numbness, or tingling? 1. Any prescription or
2. Do you have seizure activity? nonprescription medications
3. Do you experience Dizziness, 2. Smoking?
lightheadedness, or problems 3. Wearing of seatbelts/ protective
with balance or coordination? headgear?
4. Decrease in ability to smell or 4. Daily diet?
taste? 5. Exposure to lead, insecticides,
5. Ringing in Ears? pollutants, chemicals?
6. Change in vision? 6. Lifting of heavy objects?
7. Difficulty understanding when 7. Frequent repetitive
people are talking to you or movements?
when you talk to others? 8. Functioning/daily activities?
8. Difficulty in swallowing?
9. Loss of bowel or bladder
control?
10.Memory loss?
11.Tremors?
PAST HISTORY
1. Head Injury
2. Meningitis
3. Encephalitis
4. Spinal Cord injury
5. Stroke
6. Treatment received?
FAMILY HISTORY
1. High Blood Pressure
2. Stroke
3. Alzheimer’s disease
4. Epilepsy
5. Brain Cancer?
6. Huntington chorea?