Follow Us:
Send Us Inquiry:
[email protected]
Emergency Help:
Home
About Us
Providers
Services
Objective TBI Testing (VNG)
Telemed
Vestibular Therapy
Exercise With Oxygen Therapy
Neurological Consultation
Conditions treated
Neck Pain
Joint Pain
Back Pain
Concussion/traumatic Brain Injury
Headaches/migraines
Car Accident
Myofascial Pain
Nervous System Trauma
Vertigo/dizziness/imbalance
Muscular Dystrophy
Nerve Pain
Locations
Winston Salem, NC
Cincinnati, Ohio
Columbus, Ohio
Beachwood, Ohio
Lakewood, Ohio
Dayton, Oh
Contact
Client Symptoms Form
Careers
Home
About Us
Providers
Services
Objective TBI Testing (VNG)
Telemed
Vestibular Therapy
Exercise With Oxygen Therapy
Neurological Consultation
Conditions treated
Neck Pain
Joint Pain
Back Pain
Concussion/traumatic Brain Injury
Headaches/migraines
Car Accident
Myofascial Pain
Nervous System Trauma
Vertigo/dizziness/imbalance
Muscular Dystrophy
Nerve Pain
Locations
Winston Salem, NC
Cincinnati, Ohio
Columbus, Ohio
Beachwood, Ohio
Lakewood, Ohio
Dayton, Oh
Contact
Client Symptoms Form
Careers
[email protected]
Home
About Us
Providers
Services
Objective TBI Testing (VNG)
Telemed
Vestibular Therapy
Exercise With Oxygen Therapy
Neurological Consultation
Conditions treated
Neck Pain
Joint Pain
Back Pain
Concussion/traumatic Brain Injury
Headaches/migraines
Car Accident
Myofascial Pain
Nervous System Trauma
Vertigo/dizziness/imbalance
Muscular Dystrophy
Nerve Pain
Locations
Winston Salem, NC
Cincinnati, Ohio
Columbus, Ohio
Beachwood, Ohio
Lakewood, Ohio
Dayton, Oh
Contact
Client Symptoms Form
Careers
Client Symptoms Form
Home
Client Symptoms Form
Client Symptom Questionnaire
Patient’s Name*
Last name*
Email Address*
Mobile Number*
Is this related to an auto accident or work injury?
Auto Accident
Work Injury
Incident Date
Today’s Date
PLEASE CHECK ALL THAT APPLY :
Head
NECK PAIN
HEADACHES
FACE PAIN
DIZZINESS
DIFFICULTY WALKING
BALANCE PROBLEMS
CONFUSED
DAYDREAMING
ATTENTION ISSUES
HEARING ISSUES
DIFFICULTY SPEAKING
MEMORY LOSS
TIRED OR FATIGUED
APPETITE CHANGE
DIFFICULTY SLEEPING
BLURRED VISION
NAUSEA/VOMITING
MOOD SWINGS
SADNESS
AGITATION
DISORIENTED/ROOM SPINS
CHANGE IN SENSE OF SMELL/TASTE
VISUAL DISTURBANCES
FLASHBACKS TO ACCIDENT
PROBLEMS READING OR WRITING
Neck
NECK PAIN, NUMBNESS, TINGLING, AND/OR WEAKNESS THAT RADIATES OR GOES DOWN TO RIGHT/LEFT SHOULDER, ARM, FOREARM, ARM
NECK PAIN THAT CAUSES HEADACHES
NECK OR SHOULDER SPASMS
NECK PAIN THAT CAUSES HEADACHES
POPPING OR CLICKING SOUND
Back
UPPER, MID, OR LOW BACK PAIN
BACK SPASMS
BACK PAIN, NUMBNESS, TINGLING, AND/OR WEAKNESS THAT RADIATES OR GOES TO RIGHT/LEFT SHOULDER, ARM, FOREARM, HAND
OTHER SYMPTOMS:
Submit
Appointment Booking
Powered by
Bookly
—
WordPress Booking Plugin
Contact us Today
Name
Email
Phone no
Message
Submit
