Complete the CE Checklist for Customized Symptoms. Page 1 of 6
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1 Progress Tracking Complete the CE Checklist for Customized Symptoms Page 1 of 6
2 Generic Positive Symptom Tracking Concentration Quality Of Sleep Motivation/Energy Patience Short Term Memory Appetite Positive Moods Assertiveness Generic Negative Symptom Tracking Restlessness Negative Moods* Pain/Physical Discomfort Irritability Worry/Negative Thinking Negative Emotions* Fatigue Impulsivity** Sleep Tracking Teeth grinding Bedwetting Periodic leg movements Restless leg Restless sleep Sleep apnea Sleep walking Snoring Talking during sleep Difficulty falling asleep Difficulty staying sleep Difficulty waking up Dysregulated sleep cycle Narcolepsy Night sweats Night terrors Nightmares or vivid dreams Concentration Tracking Difficulty completing tasks Difficulty following directions Difficulty making decisions Difficulty organizing personal time or space Difficulty remembering names Not listening Poor concentration Poor drawing ability Poor math Poor short-term memory Page 2 of 6
3 Difficulty shifting attention Difficulty shifting tasks Difficulty thinking clearly Difficulty understanding conversations Poor sustained attention Poor verbal expression Poor vocabulary Poor word finding Distractibility Reading difficulty Lack of alertness Lacking common sense Messy handwriting Slow thinking Unmotivated Sensory Tracking Auditory hypersensitivity Chemical sensitivities Motion sickness Poor body awareness Somatosensory deficits Tinnitus Vertigo Visual deficits Visual hypersensitivity Behavior Tracking Addictive behaviors Aggressive behavior Anorexia Autistic stimming Binging and purging Class clown Compulsive behaviors Compulsive eating Crying Excessive talking Hyperactivity Impulsivity Inflexibility Lack of appetite awareness Lack of sense of humor Lack of social interest Manipulative behavior Motor or vocal tics Nail biting Oppositional or defiant behavior Poor eye contact Poor grooming Poor social or emotional reciprocity Poor Speech articulation Rages Self-injurious behavior Stuttering Trouble doing anything because felt bad Page 3 of 6
4 Emotion Tracking Agitation Lack of emotional awareness Lack of pleasure Lack of social awareness Low self-esteem Mania Mood swings Obsessive negative thoughts Obsessive worries Panic attacks Paranoia Suicidal thoughts Sexual indifference Anger Anxiety Depression Difficult to soothe Dissociative episodes Easily embarrassed Emotional reactivity Fears Feelings of unreality Flashbacks of trauma Impatience Phobias Emotion 2 Tracking Worry Socially Inappropriate Self-Deprecation Over control of Emotion Hyperactive Attention Hyper arousal Excessive Rationalization Emotional Rumination Victim Mentality Socially Cavalier Passive Aggressiveness Irritability Hyper vigilance Excessive Self-Concern Emotionally Impulsive Dislike of Novelty. Cognitive Tracking Attention Problems Auditory Verbal Sequence Problems Decision Making Problems Digit Span Problems Math Problems (Acalcula) Poor Dialogue Organization Auditory Tone Processing Problems Categorization Problems Declarative & Episodic Memory Problems Event Sequence Problems Motivation Problems Poor Facial Recognition Page 4 of 6
5 Poor Figure Memory Procedural Memory Problems Short Term Memory Difficulty Short Term Visual Memory Problems Tone Sequence Problems Working Memory Problems Problem Solving Difficulties Reading Comprehension Short Term Verbal Memory Problems Spatial Sequencing Problems Verbal Sequencing Problems Physical Tracking 1 Allergies Asthma Chronic constipation Clumsiness Difficulty walking or moving Difficulty working Effort fatigue Encopresis Fatigue Heart palpitations High blood pressure Nausea PMS symptoms Poor balance Poor fine motor coordination Poor gross motor coordination Reflux Rigidity Seizures Skin rashes Spasticity Stress incontinence Physical Tracking 2 Hot flashes Immune deficiency Irritable bowel Low muscle tone Muscle tension Muscle twitches Always sickly Amnesia Labored breathing Lump in throat Bulimia Sugar craving and reactivity Sweating Tachicardia Tremor Urge incontinence Abdominal bloating Insomnia Anxiety attacks Aphonia (loss of voice above a whisper) Menstrual irregularity Paralysis Page 5 of 6
6 Physical Tracking 3 Ringing in ears Spasms Excessive menstrual bleeding Urinary retention Visual blurring Fits or convulsions Weakness Weight loss Heartburn Dizziness Sudden weight fluctuation Unconsciousness Fainting spells Vomiting Food intolerances Frigidity (absence of orgasm) Indigestion Pain Tracking Abdominal pain Chronic aching pain Chronic nerve pain Fibromyalgia pain Jaw pain Joint pain Headaches Extremity pain Chest pains Dysmenorrhea-other Dysuria (painful urination) Muscle pain Muscle tension headaches Sciatica Sinus headaches Stomach aches Trigeminal neuralgia Burning pains in rectum, vagina, or mouth Other bodily pains Dysmenorrhea (painful menstruation) Dyspareunia (painful sexual intercourse) Page 6 of 6
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Ashok K. Modh, M.D., F.C.C.P. Naishadh K. Mandaliya, M.D., F.C.C.P. Jerges J. Cardona, M.D. Nirav B. Patel, M.D. Dear, Your physician has requested that you be scheduled for a sleep study. Your appointment
SINAN DUZYUREK, MD, PLLC
PATIENT INTAKE FORM- CLINICAL INFO SECTION Your Name: Today s Date: Reasons for Seeking Professional Evaluation and/or Treatment During your session today Dr. Duzyurek will be conducting a diagnostic interview
CHECKLIST OF CONCERNS AND HISTORY FORM
CHECKLIST OF CONCERNS AND HISTORY FORM Name: Date: Please mark any items that apply to you. PROBLEM AREAS--CAREER, SCHOOL Career concerns, goals, and choices Unemployment Job stress School problems Learning