Go to top
american-imagingorig

PATIENT SYMPTOMS FORM

PRxLogo

Mobile Full Body Diagnostic Imaging

Clinical Symptoms Intake:         Please check ANY of the following symptoms that you may have.
Symptoms
Side of the Body
 
Both Sides
Left Side
Right Side
Back Pain
Pain in your lower back
Pain in your buttocks
Leg Pain
Pain or burning in your legs
Numbness or tingling in your legs
Weakness in your legs
Loss of strength in your legs
Foot Pain
Pain or burning in your feet
Numbness or tingling in your feet
Pins and needles in your feet
Increased sensitivity to touch in your feet
Trouble feeling hot or cold in your feet
Trouble feeling your feet when you walk
Discomfort or pain at night in your feet
Wrist, Hand or Finger Pain
Burning in your fingers
Numbness or tingling in your fingers
Difficulty gripping things with your hands
Difficulty forming a fist with your hand
Discomfort in hands wakes you up at night
Neck Pain
Burning in your neck
Numbness or tingling in your neck
Pain in your neck
Discomfort in your neck wakes you up at night
Coldness in your neck