New Patient Form | Cathryn Harbor Md

Symptoms (please select all that apply for each category)

Fatigue that keeps me from doing things

Chills

Night sweats

Fainting

Unexplained or recurrent fevers

Symptoms that worsen seasonally

Eyes

Changes in vision

Pain behind eyes

Red or burning eyes

Trouble understanding or interpreting visual input

Sensitivity to light

Ears, Nose, Throat, and Teeth

Hearing loss

Chronic stuffy nose

Chronic sore throat

Hypersensitivity to sound

Ringing in ears

Sensitivity to strong odors

Mercury fillings

Other teeth problems

Lungs and Airways

Shortness of breath

Coughing

Wheezing

Air hunger

Pain around rib cage

Heart and Circulation

Chest pain

Exercise related shortness of breath

Skipped heartbeats or palpitations

Cold hands and/or feet

Swelling in feet

POTS - inability to stand for long periods of time due to a racing heart and dizziness

Digestion

Heartburn

Lower abdominal pain

Constipation

Frequent diarrhea

Bloating

Discomfort immediately after eating

Delayed discomfort or other symptoms after certain meals or foods

Urinary System

High urinary frequency

Pain with urination

Bladder pain

Incontinence or leaking problems

Muscles, Bones, and Joints

Joint pain (large joints)

Joint redness

Back pain

Hand or foot pain

Muscle weakness

Muscle spasms

Muscle aches

Muscle twitches

Muscle cramps

Foot cramps

Brain and Nervous System

Dizziness

Numbness or tingling

Tremors

Fainting or loss of consciousness

Involuntary movements

Difficulty with memory

Difficulty concentrating

Difficulty with balance

Difficulty with thinking

Difficulty with judgement and/or decision making

Difficulty speaking well

Headaches (check what applies to your most common headache, if you do not experience frequent headaches please skip this section)

Back of head/top of neck

Top of head

Sinus

Forehead or eye area

Migraines

Worse in the morning

Worse in the evening

Triggered by smells

Skin and Nails

Rashes

Dark red stretch marks

Hives

Itchy skin

Flushing

Brittle nails

Nails that curve upwards

Nail fungus

White spots on nails

Circulation

Swollen lymph nodes

Easy/frequent bruising

Hormones

Difficulty tolerating hear or cold

Increased thirst

Excessive urination

Decreased libido (sex drive)

Unexpected weight change

Salt cravings

Excessive sweating

Mood

Stress due to illness

Time stress

Relationship stress

Financial stress

Sadness or depression

Anxiety

Irritability or crankiness beyond your normal

Strong or excessive reactions of: rage, despair, anxiety

Sleep

Daytime sleepiness

Difficulty falling asleep

Difficulty staying asleep

Early waking (problematic and unexplained)

Nightmares

Exposures

Tick bite(s)

Erythema Migrans (bullseye) rash

Cat scratches, bites, or high exposure to sneezing cats

Exposures to toxic metals

Severe or prolonged Mono

Repeated or prolonged use of antibiotics

More than 2 doses of steroids

Flooding or leaking in home or at work

Musty smell at home, in basement, or at work

Symptoms increase in a specific location

Food Habits

I eat out a lot

I avoid gluten

I avoid dairy

I follow a paleo, autoimmune, or ketogenic diet

I limit my diet because of food allergies or intolerances

I drink sweetened beverages most days

I do not eat green vegetables

Other Habits

I drink alcohol regularly

I worry that I drink more than is healthy

I am a recovering alcoholic/drug addict

I use tobacco products

I vape

I use my cellphone

New Patient Information