Consultation Progress Form 1 Todays Date MM slash DD slash YYYY Name First Last Physician Name (Dr. First/Last) Primary Diagnoses PhonePlease Answer Yes Or No For The FollowingDo You Experience Anxiety? Yes No MedicineIf you are experiencing more than one symptom or are using more than one method of application, please click the plus icon to the right and fill out a new line for each additional symptom/modality. SymptomModalityDose-mgEffectivenessDurationComments Add RemoveComments/QuestionsDo You Experience Depression? Yes No MedicineIf you are experiencing more than one symptom or are using more than one method of application, please click the plus icon to the right and fill out a new line for each additional symptom/modality. SymptomModalityDose-mgEffectivenessDurationComments Add RemoveComments/QuestionsDo You Experience Seizures? Yes No MedicineIf you are experiencing more than one symptom or are using more than one method of application, please click the plus icon to the right and fill out a new line for each additional symptom/modality. SymptomModalityDose-mgEffectivenessDurationComments Add RemoveComments/QuestionsDo You Experience Neuropathy? Yes No MedicineIf you are experiencing more than one symptom or are using more than one method of application, please click the plus icon to the right and fill out a new line for each additional symptom/modality. SymptomModalityDose-mgEffectivenessDurationComments Add RemoveComments/QuestionsDo You Experience Spasticity? Yes No MedicineIf you are experiencing more than one symptom or are using more than one method of application, please click the plus icon to the right and fill out a new line for each additional symptom/modality. SymptomModalityDose-mgEffectivenessDurationComments Add RemoveComments/QuestionsDo You Have Trouble With Sleep? Yes No MedicineIf you are experiencing more than one symptom or are using more than one method of application, please click the plus icon to the right and fill out a new line for each additional symptom/modality. SymptomModalityDose-mgEffectivenessDurationComments Add RemoveComments/QuestionsDo You Experience Pain? Yes No MedicineIf you are experiencing more than one symptom or are using more than one method of application, please click the plus icon to the right and fill out a new line for each additional symptom/modality. SymptomModalityDose-mgEffectivenessDurationComments Add RemoveComments/QuestionsDo You Have Fibromyalgia? Yes No MedicineIf you are experiencing more than one symptom or are using more than one method of application, please click the plus icon to the right and fill out a new line for each additional symptom/modality. SymptomModalityDose-mgEffectivenessDurationComments Add RemoveComments/QuestionsDo You Experience Migraines? Yes No MedicineIf you are experiencing more than one symptom or are using more than one method of application, please click the plus icon to the right and fill out a new line for each additional symptom/modality. SymptomModalityDose-mgEffectivenessDurationComments Add RemoveComments/QuestionsDo You Experience Joint Pain or Arthritis? (Please specify in comments) Yes No MedicineIf you are experiencing more than one symptom or are using more than one method of application, please click the plus icon to the right and fill out a new line for each additional symptom/modality. SymptomModalityDose-mgEffectivenessDurationComments Add RemoveComments/QuestionsDo You Experience Muscle Pain? Yes No MedicineIf you are experiencing more than one symptom or are using more than one method of application, please click the plus icon to the right and fill out a new line for each additional symptom/modality. SymptomModalityDose-mgEffectivenessDurationComments Add RemoveComments/QuestionsDo You Experience Psoriasis or Dry Skin? (Please specify in comments below) Yes No MedicineIf you are experiencing more than one symptom or are using more than one method of application, please click the plus icon to the right and fill out a new line for each additional symptom/modality. SymptomModalityDose-mgEffectivenessDurationComments Add RemoveComments/QuestionsDo You Experience Tremors? Yes No MedicineIf you are experiencing more than one symptom or are using more than one method of application, please click the plus icon to the right and fill out a new line for each additional symptom/modality. SymptomModalityDose-mgEffectivenessDurationComments Add RemoveComments/QuestionsAre You Currently Undergoing Chemotherapy? Yes No MedicineIf you are experiencing more than one symptom or are using more than one method of application, please click the plus icon to the right and fill out a new line for each additional symptom/modality. SymptomModalityDose-mgEffectivenessDurationComments Add RemoveComments/QuestionsAre You Medicated For Other Purposes? (Please Specify One Aliment Per Line) Yes No MedicineIf you are experiencing more than one symptom or are using more than one method of application, please click the plus icon to the right and fill out a new line for each additional symptom/modality. SymptomModalityDose-mgEffectivenessDurationComments Add RemoveComments/Questions