Returning Visit Form

Returning Visit Form
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Do you have a copay or deductible?*
Any change to insurance:*
Check the symptoms that you have experienced in the PAST 6 WEEKS*

Fever/ChillsUnexplained change in weightFatigue/Malaise/Generalized weaknessHeadaches/MigrainesDizzinessSinus Pain/Pressure/DischargeVision changesWheezing/Chronic CoughShortness of breathChest pain, pressure or tightnessSwelling of hands/feet/anklesNausea/VomitingAbdominal painHeartburnConstipation or diarrheaStiffness/Pain in joints/musclesJoint swellingBleeding/Easy bruisingExcessive urinationExcessive thirst/hungerHot flashesPainful/Bloody urinationDifficulty urinating/Night-time urinationUrinary incontinence (leakage)Vaginal discharge or painRashAnxiety/Panic AttacksDepressionInsomnia/Problems with SleepThoughts of harming self or othersNONE
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