Symptom Screening Form
As the patient of Dr. Xander M. Spencer, please fill this form periodically.
Patient Name
First Name
Last Name
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Period of the day
Morning (6 AM - 12 PM)
Afternoon (12 PM - 6 PM)
Evening (6PM - 12 AM)
Other
Which symptoms have you experienced in this period?
Headache
Nausea
Dizziness
Sensitivity to light
Blurred vision
Vomiting
Loss of appetite
Fever
Sensations of being very warm or cold
What type of activities have you done? Please briefly explain.
What have you eaten/drank on this period?
How much water have you drank? (One cup is of 200 cc)
1-2 cups
3-4 cups
4-5 cups
5-6 cups
Other
If you're on medication, did you take your medication?
Yes
No
If exists, explain other triggers that affect your headache.
Submit
Should be Empty: