Appointment with Tony Cassis - 1a/10 Small St, Hampton , 3188

First

Last

Date of Birth (dd/mm/yyyy)

Email *

Choose one option for each of the following questions. Answer each question as it relates to how you have been feeling in the past month

1. I feel unrefreshed when I wake up in the morning *

2. My muscles feel stiff and achy *

3. I have anxiety attacks *

4. I grind or clench my teetch *

5. I have problems with diarrhoea and/or constipation *

6. I need help in performing my daily activities *

7. I am sensitive to bright lights *

8. I get tired easily when I am physically active *

9. I feel pain ALL OVER my body *

10. I have headaches *

11. I have discomfort in my bladder and/or burning when I urinate *

12. I do not sleep well *

13. I have difficulty concentrating *

14. I have skin problems such as dryness, itchiness or rashes *

15. Stress makes my physical symptoms get worse *

16. I feel sad or depressed *

17. I have low energy *

18. I have tension in my neck and shoulders *

19. I have pain in my jaw *

20. Certain smells, such as perfumes make me feel dizzy and nauseated *

21. I have to urinate frequently *

22. My legs feel uncomfortable and restless when I am trying to get to sleep of a night *

23. I have difficulty remembering things *

24. I suffered trauma as a child *

25. I have pain in my pelvic area *

We would now like you to complete following section. Have you ever been diagnosed with one of the following disorders? Please tick the box if you have

CSI-Part B *

Share this:

Like this: