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(903) 838-5500
TEXARKANA CARDIOLOGY ASSOCIATES
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James Hurley, M.D.
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First name
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Multi-line address
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Address
City
Zip / Postal code
Sex
Social Security Number
General Symptoms (Select all that apply)
Chills
Depression
Dizziness
Fainting
Fever
Forgetfulness
Headache
Loss of Sleep
Loss of Weight
Nervousness
Numbness
Sweats
Pain, weakness, or numbess in?
Arms
Back
Feet
Hands
Hips
Legs
Cramping When Walking
Neck
Shoulders
Genito-Unirary Symptoms?
Blood in Urine
Frequent Urination
Lack of Bladder Control
Painful Urination
Gastrointestinal Symptoms?
Poor Appetite
Bloating
Bowel Changes
Constipation
Diarrhea
Excessive Hunger
Excessive Thirst
Gas
Hemorrhoids
Indigestion
Nausea
Rectal Bleeding
Stomach Pain
Vomiting
Vomiting Blood
Cardiovascular Symptoms?
Chest Pain
High Blood Pressure
Irregular Heart Beat
Low Blood Pressure
Poor Circulation
Rapid Heart Beat
Swelling of ankles
Varicose Veins
Eye, Ear, Nose, Throat
Bleeding Gums
Blurred Vision
Crossed Eyes
Difficulty Swallowing
Double Vision
Earache
Ear Discharge
Hay Fever
Hoarseness
Loss of Hearing
Bruise Easily
Nosebleeds
Persistent Cough
Ringing in ears
Sinus Problems
Vision - Flashes
Vision - Halos
Skin
Bruise Easily
Hives
Itching
Change in Moles
Rash
Scars
Sore Throat Won't Heal
Conditions
AIDS
Alcoholism
Anemia
Anorexia
Appendicitis
Arthritis
Asthma
Bleeding Disorders
Breast Lump
Bronchitis
Bulimia
Cancer
Cataracts
Chemical Dependency
Chicken Pox
Diabetes
Emphysema
Epilepsy
Glaucoma
Goiter
Gonorrhea
Gout
Heart Disease
Hepatitis
Hernia
Herpes
High Cholesterol
HIV Positive
Kidney Disease
Liver Disease
Measles
Migraine Headaches
Miscarriage
Mononucleosis
Multiple Sclerosis
Mumps
Pacemaker
Pneumonia
Polio
Prostate Problem
Psychiatric Care
Rheumatic Fever
Scarlet Fever
Stroke
Suicide Attempt
Thyroid Problems
Tonsillitis
Tuberculosis
Typhoid Fever
Ulcers
Vaginal Infections
Vaginal Diseases
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