Dry Eyes/GI Questionnaire
First and Last (ex: N.C.)
What type of headache symptoms do you get? (check all that apply)
Location of headaches (check all that apply)
Top of Head
Behind the eye(s)
Do you get tingling sensations on any part of your body?
If Yes, what part(s) of the body?
Do you have neck or back instability?
If Yes, specify where:
Do you see someone to adjust your spine? (Chiropractor, massage therapist, etc)
If Yes, why?
Do you have to urinate frequently or feel the urge?
If Yes, how often?
Do you have dry eyes? (How much does it bother you?)
0 is None, 10 is Severe
Do you have any of these symptoms?
Any other symptoms not listed above that you might be experiencing?
Should be Empty: