Current Symptoms

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My Name goes here
Date: Tuesday, February 9, 2016
Current Medical Summary
Contact details:
Name:
Address:
Ph:
Mob:
Hospital UR No:
Next of Kin/Carer
Name:
Relationship:
Ph:
Doctor’s Details:
Dr. Robert Robers: The Clinic From Hell – 666 Hell Rd, Hades, 666. Ph: 666666666666
Specialist’s Details:
Mr. Know it all and costs a fortune: 1 Best St, Best Part of Town.
Medications:
AM:

Good Drug 100 mg

Nice Drug 75 mg

Stupid drug with stupid side effects 100 mg

Sleepy Drug 20 mg

Anti-Igloo Drug 500 mcg x 2
PM:
As needed:

Beasty Pain Killer 100,000 mg x 10
Supplements:

Vitamins that don’t work but I take them just in case 500 mg
1|P a g e
My Name goes here
Date: Tuesday, February 9, 2016
Allergies/Intolerances

Wheat, rice, etc
Diagnosis

Chronic Fatigue Syndrome/Myalgic Encephalomyelitis.

Fibromyalgia.

Orthostatic intolerance/Postural Orthostatic Tachycardia Syndrome.
Acute Symptoms (life-threatening reactions)

Peanuts

Penicillin
Current Symptoms:

Extreme, constant fatigue exacerbated by exercise

Cannot stand for more than 10 minutes without experiencing extreme fatigue, nausea and pain.

Reoccurring headaches/migraines. Triggered by light, noise, fatigue.

Cognitive dysfunction (also known as brain fog). The loss of intellectual functions such as thinking,
remembering, and reasoning of sufficient severity to interfere with daily functioning. Patients with
cognitive dysfunction have trouble with verbal recall, basic arithmetic, and concentration.

Body pain (Fibromyalgia). Treatment – Tramadol, Lyrica, Panadine Forte

Irritable bowel syndrome – constipation and diarrhea, severe stomach cramps, explosive farts. Managed
with very strict diet which helps reduce the severity of the symptoms but does not eliminate them.

Sleep disturbance – No sleeping pattern whatsoever. Pain levels dictate when I can sleep.
Notes:

Reason for today’s visit

Meds needed

2|P a g e
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