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Suzanne Rosenberg, MD
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Concussion Information for Families
Concussion Patient Intake
Medical History--All patients please complete
Patient Information-- All patients please complete
Medical History--All patients please complete
Name
Reason for Visit
Date of birth
Current Medications
Please list all medications, vitamins, supplements, or write NONE
Allergies
*
Please list or write NONE
Medical diagnoses, problems or concerns
Past Surgeries
Please list any current therapies
ie, PT, OT, Speech, Vestibular, Vision or other
Please check all that apply
Fever
Chills
Weight change
Rashes
Skin Sores
Joint Pain
Contractures
Neck/back pain
Headaches
Dizziness
Light sensitivity
Sound sensitivity
Eye Pain
Change in vision
Hearing loss
Ear Pain
Bloody nose
Sinus pain
Motion Sickness
Dental pain
TMJ
Recent cold symptoms
Shortness of breath
Palpitations
Constipation
Reflux
Urinary incontinence
Bladder problems
Weakness
Numbness
Vertigo
Depression Screen
Feeling sad or empty
Loss of interest in daily activities
Weight loss without dieting
Less ability to think /concentrate
Tearfulness
Feeling worthless
Thoughts of death or suicide
Please check all that apply
Family History
Migraines
Neurologic problems
Muscle problems
Pain issues
Heart Disease
Depression
Psychiatric disease
Concussions
Mood disorders
Physicians to whom you would like your notes sent
Please list name, phone number and FAX if available
* Required field
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