Schedule

Speciality -Please Select- PEDIATRIC OB-GYNECOLOGY CARDIOLOGY PLASTIC SURGERY DENTAL

Care Giver -Please Select- Mohammad Fouda Amal Abu Talib Tamaam Saqr Badr Al Daghish Suhair Mahmud Nizar Muhammad Haitham Yassin Elham Adly Murad Al-Murad Faisal Mustafa Saeed Jihad Hammoud Ahmed Al-Kholy Intisar Al-Absi

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Personal Info

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National ID#

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Name Arabic *

Patient Name *

Gender

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Female

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Age

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Patient Appointment

Reason for Appointment Select Reason for Appointment Primary Consultation Followup Consultation For Visit Patient Counseling

. Chief Complaint

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Diseases Symptoms Abdominal distension Abdominal swelling (Stomach swelling) Abnormal breathing sounds Abscess (Collection of pus) Agitated Alcohol abuse Alopecia (Hair loss) Altered mental status (confusion) Amenorrhea ( No menstruation) Anger Ankle pain Anxiety (Nervousness) Aphasia (Trouble speaking) Arm ache or pain Arm cut (laceration) Arm itching Arm numbness (Paresthesias) Arm redness Arm swelling Armpit pain Ataxia (Incoordination) Axillary pain Back ache or pain Behavioral disturbances Behavioral problem Bitterness Black stools Bleeding gums Bleeding in brain Bleeding tendency Blindness Blister ( Pocket of fluid ) Bloating Blood in stool Blood in urine (Hematuria) Blood in vomit Blood shot eyes Bloody in diarrhea Bloody nose (Epistaxis) Blue skin tone Blurry vision Blurry vision and eye pain Body aches Boil (Furuncle) Bradycardia (Slow heart rate) Bruising Bulging abdomen Burning with urination Calf pain Calf swelling Can't keep food down Change in behavior Chest Pain Chest burning Chest pressure Chest tightness, heaviness or pressure Childhood limping Chills Choking Collection of pus Confusion and headache Constipation Convulsions Cough Coughing blood Cranky,crying,fussy,irritable child Croupy cough Crying baby Cuts Cyanosis (Blue skin coloration) Dark Stools Darkening of the skin (Hyperpigmentation) Decreased mental status Decreased stools Delusions or hallucinations Dementia Dental problem Depressed Diarrhea Difficulty breathing Difficulty with walking Diplopia (Seeing double) Dizziness Double vision (Diplopia) Drak stools Drooling Drooping eyelid (Ptosis) Drug abuse Dry heaves Dry skin Dryness,peeling or scaly skin Ear pressure Ear swelling Easy bruising Elbow ache or pain Elbow Swelling Elevated blood calcium Elevated temperature Excessive appetite Excessive drinking Eye floaters Eye pain (Irritation) Eye redness Eye swelling Face numbness (paresthesias) Face pain Facial droop (Weakness) Facial pain Failure to thrive Fainting Fainting spells Fatigue Fatty stools Feeling down Fever Fever in the returning traveler Fever of unknown origin Finger pain Flank pain Flashes of light Flatulence (Passing gas) Foot cut (laceration) Foot itching Foot numbness (paresthesias) Foot pain Foot redness Foot swelling Frequent urination (Frequency) Gas General weakness Groin pain Gum pain Gum swelling Hair loss (Baldness) Hand cut (laceration) Hand itching Hand numbness (paresthesias) Hand pain Hand redness Hand,finger ache or pain Hand,finger swelling Head injury Head pain Headache Headache after trauma Headache and weakness Heart murmur (Abnormal heart sound) Heart pulsations and palpitations Heat illness Heel pain Hemoptysis (Coughing blood) Hip pain Hives Hoarse voice Hot flashes Hot skin Hypercalcemia (Elevated blood calcium) Hyperpigmentation (Darkening skin) Hypoglycemia Hypotension Hypothermia (Low temperature) Impotence Inconsolable baby Incontinence (Ieaking urine) Incoordination Increased facial hair Increased thirst Increased urination (Polyuria) Infertility (Female) Ingestion Insect bite Insect sting Insomnia (Trouble sleeping) Irregular periods (Irregular menses) Irritated eyes Itching feet Itchy eyes Itchy rash (Pruritic rash) Jaundice (Yellowing skin) Jaw pain Joint pain Joint stiffness Kidney pain (Flank pain) Knee pain Laceration Lack of energy Leaking urine Learning difficulties Leg ache or pain Leg cut (laceration) Leg itching Leg numbness (Paresthesias) Leg redness Leg swelling Lethargy (Sluggishness) Lightheaded Limping in a child Lip swelling Liver failure (Cirrhosis) Loose stools Loss of balance Loss of consciousness Loss of coordination Loss of memory Loss of vision (Blindness) Low back ache or pain Low blood pressure (Hypotension) Low bloodsugar (Hypoglycemia) Low heart rate Low temperature Lower abdominal pain Lower belly pain Lower extremity edema (swelling) Lower leg pain Lump or mass of breast Maroon stools Melena (Black stools from blood) Memory loss Missed periods Mouth pain Mouth sore Mouth Swelling Mouth ulcers Muscle aches Muscle cramps Muscle pain Muscle spasm Muscle weakness Nail Injury Nasal Bleeding Nasal congestion Nasal injury Nausea Neck ache or pain Neck mass Neck swelling Nervousness Night sweats Nipple discharge Nose bleed Nose injury Numbness Obesity Out of breath Overdose Overweight Pain in the ear Pain or soreness of breast Painful gums Painful rash Painful skin Painful urination Panic attack Paresthesias (Numbness) Passing out Pedal edema Pelvic pain Penile discharge Penis pain Poisoning Pregnancy problem Protruding abdomen Psychiatric problem Ptosis (Drooping eyelid) Puncture wound Pustule (Collection of pus) Rash Rectal pain Rectal swelling Red eyes Retaining fiuid Rigors Ringing in ears (Tinnitus) Room spinning Runny nose Sadness Scrotal pain Scrotal swelling Seizure Shakes Shaking Shin pain Shortness of breath Shoulder ache or pain Shoulder stiffness or tightness Side pain Sinus pain and pressure Skin darkening Skin growths Skin infection Skin itching Skin lesion Skin pain Skin rash Skin sores Skin swelling Skin trauma Skin ulcers Skipped heart beat Skipped periods Sleep disorders Sleeping problem Slow heart rate (Bradycardia) Sluggishness Slurred speech Smoker's cough Snake bite Sneezing Snoring Sore skin Sore throat Speech problem Spider bite Spinal pain Spinning Spontaneous bleeding Steatorrhea (Excess fat in stool) Sterility (Female) Stinging urination Stings Stomach and abdominal pain Stuffy nose Substance abuse (Drug abuse) Suicidal tendencies Swallowing problem (Dysphagia) Sweating Sweating at night Swelling Swelling of both ankles Swelling of both legs Swollen eye Swollen foot Swollen gums Swollen lip Swollen lymph nodes (Large lymph nodes) Swollen mouth Swollen skin Tarry Stools Testicle pain Thigh pain Throat pain Throwing up Tingling Tired Toe pain Tongue swelling Tooth pain Trauma Traveler's diarrhea Tremors Trouble sleeping Trouble speaking Twitching Unhappy Unsteady gait (Trouble walking) Unsual color or odor of urine Upper abdominal pain Upper belly pain Upper leg pain Upset stomach Urinary retention (Inability to urinate) Urticaria (Hives) Vaginal bleeding Vaginal Bleeding after menopause Vaginal Bleeding during Pregnancy vaginal discharge Vaginal itching Vaginal pain Vertigo (Room spinning) Visual Problems Visual flashing lights Vomiting Vomiting blood Vomiting coffee ground material Warm skin Weakness (Muscle localized) Weight gain Weight loss, unexplained Wheezing (Noisy breathing) Wrist pain Wrist swelling Yellow skin Pain Bleeding Weakness Abdominal Pain Palpitatious Impaired Judgment Confusion Excessive sweating Rapid Heart Rate Brain Damage Painful Periods Painful Intercourse Pain with bowel movements Pelvie or Back Pain