عوارض جسمی و ذهنی انگلیسی

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First name & Last name *

Phone Number *

Referred By, Mr./Ms

BirthDay *

National/Passport number *

Sex *

Weight (kg) *

Height (cm) *

BMI

Blood Pressure

(FBS) Fasting Sugar

Education *

1st Infection Coronavirus Sars-cov-2

Coronavirus Total Infections

Duration, First Bed Stay

Coronavirus First Vaccination

Type of vaccine

Number of vaccinations

Procedure

Tonsillectomy
Appendectomy

If Any Deseases Or Symptoms And Taking Medications, Please Explain

Complete the appearance and onset of each of the following symptoms and complications by checking the box next to it and stating the approximate date of each case.

1

Appearance of Pinkish Rosacea Like, Butterfly Shape, Covering Nose And Extending To Cheeks, Sides Of Lips And Above Upper Lip and Mid-Eyebrows

Year Of Appearance *

Pictures Of Some Sample Facial Redness, More Or Less.

2

Chronic Sleepiness, Multiple Waking-Up and being Restless

Year Of Appearance *

3

Nightmare, Stressful. Interrupted Sleep

Year Of Appearance *

4

Fluid Dreams, Story/Life-Like Scenes, Including Deceased and Familiar Persons

Year Of Appearance *

5

Hearing, Intrusive Repetitive Songs/Sentences,Specially At Waking-Up Time

Year Of Appearance *

6

Impulsive Finger/Hand Twitching/Jerking

Year Of Appearance *

7

Deep Shoulders Pain‬‬‬

Year Of Appearance *

8

Restless Leg/Arm Syndrome

Year Of Appearance *

9

Constipation

Year Of Appearance *

10

Twitching of the Eyelids

Year Of Appearance *

11

Blurry Vision, Usually Left Eye, Needing To Rub The Blurred Eye

Year Of Appearance *

12

Imagining Seeing White Flash In The Dark Usually The Right Eye, And Or Early Morning Flickering

Year Of Appearance *

13

Chronic, Indigestion, Burping and Heartburn

Year Of Appearance *

14

Sudden Tendency To overeat or Change of Taste Preferences

Year Of Appearance *

15

Chronic Low Grade, Stomach Pain

Year Of Appearance *

چیدمان Of Of

16

Dysphagia, Choking, Coughing When Swallowing

Year Of Appearance *

17

Hardening of Night Eyes' Discharges, Sand-Like

Year Of Appearance *

18

Increased Nasal Discharge, with Decrease in Smelling Ability

Year Of Appearance *

19

Increase of Darker and Stickier Ear Wax While Decrease in Hearing

Year Of Appearance *

20

Biting the Tongue and Inner Lips/Cheeks While Eating/Chewing

Year Of Appearance *

21

Sudden Increase Of Scalp Dandruff And Facial Nose Skin Flaking From Area Of Item 1

Year Of Appearance *

22

Standing Balance On One Leg, Without Use Of Hand Or Leaning Against Anything, As Per Picture

Right Leg *

seconds

Left Leg *

seconds

23

In Daily Conversations Sudden, Momentary Words Forgetfulness, Tip of the Tongue

Year Of Appearance *

24

Illogical Impatience, Transient Anger, Irritability, Diminishing Orientation Of Time And Space, Bad Mood, Restlessness

Year Of Appearance *

25

Mismanagement of Financial/ Money Issues, Either Excessively Tight Fisted or Largesse and Unreasonably Free Spending

Year Of Appearance *

26

‬‬‬ Increased and Age-Excessive Sexual Subject Conversations and Desire

Year Of Appearance *

27

Marked Emotional Empathy To One’s Relations/ Surroundings and Decreasing Reaction To Humorous Stories/Situations

Year Of Appearance *

28

Recent Decrease In tidiness/Upkeep Of Personal Hygiene and Engaging In Excessive Social Interactions, Too Much or Too Little

Year Of Appearance *

29

Frequent Nightly Urination

Year Of Appearance *

30

Work In Close Proximity With Plastics And Exposure To Microfibers/ Microplastics/Polystyrenes

Year Of Appearance *

31

If You Have Observed Any Of The Above Symptoms In Any, Of Living With You, Family Members And/or ‬‬‬ Colleagues

Year Of Appearance *

Description of item 31

32

Please Add Any Other Behavioral Or Cognitive Changes

Year Of Appearance *

Description of item 32

Like the sample image below, take a clear, high-quality photo of your face, full-face from the front and a profile from the side, and upload it.

Upload a frontal image file (full face) *

برای آپلود، فایلی را به این قسمت بکشید یا کلیک کنید.

Upload a side view image file , Wearing No Collar T-Shirt (side view) *

برای آپلود، فایلی را به این قسمت بکشید یا کلیک کنید.

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