Offices : Sewell | Vineland | Philadelphia


  Contact : Telephone for all offices : (856) 589-6034

Autonomic Questionnaire

Please be advised that your information is 100% confidential

 

AUTONOMIC QUESTIONNAIRE

SELECT WHICH SYMPTOMS YOU HAVE:

  1. LightheadedFainting and near faintingFatigueBrain Fog or Mental cloudinessDifficulty findings wordsShort term memory lossSensory: hypersensitive to light, sound, motion, touchPins and needs in arms/legsNumbness in hands and feetCoat hanger pain in neck and shouldersMigraine HeadacheTension headachesNausea, vomitingDifficulty standingChest pain, palpitationsShort of breathHypermobility joints- Joints pop outDepression, anxietySweat too muchSweat too littleSalivate too little, Dry mouthCold hands or feetDimmed visionDimmed hearing or ringing in earsDoes hot or cold weather bother you

 

If you have checked several of the items above, you may have Autonomic Dysfunction.

Please call us at (856) 589-6034 to schedule an in-person or remote consultation.

You can also fill out our Contact Form

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