Comprehensive Summary of Health History

Comprehensive Summary of Health History
Thank you so much for your time in completing this summary of your health history. Your answers will help us get to know you and enable us to individualize your future training protocol.
Please provide a photo of yourself here

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Operating as a team is something we value highly here at CBFC and we want to ensure that all of our team members recognize you when you step in to our office. Please provide a close-up photo, head and shoulders is ideal. If you are a parent filling this form out, please include yourself in the photo. This photo will be included in your file so that clinicians can access it but it will not be used in any other capacity without your consent. Cancelof
Client Name*

First NameLast Name
Client Birth Date*

MonthDayYear
Date
Client Gender*
Primary Handedness*
Primary Phone Number*

Area CodePhone Number
Primary Email*
example@example.com
Client Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client Marital Status*
Please list client's occupation (list "student" if a minor)
If Student, choose the one that describes you
If someone referred you to our practice please list them here

Today's Date*

MonthDayYear
Date
Individual completing this form*
If someone other than the client is completing this form, please provide your name

First NameLast Name
Who is the client's primary physician/specialist
Please list ALL known diagnoses (or type NONE if no diagnosis)*
Please list primary symptoms of concern*
Please list your goals for brain training
Completed by Client if 18 or older
Please list your goals for brain training of minor client
Completed by Parent

	No	Mother	Father	Sibling	Grandparent	Other relative	Multiple Relatives	Unknown
Asthma
Autoimmune Disorders: such as Type 1 Diabetes, RA, Lupus, MS
Migraine
Sleep Problem
Depression
Bipolar Disorder
Anxiety
Phobias
Panic Attacks
Motor or Vocal Tics
Seizures
Eating Disorder or Obesity
Addictions
Obsessive Compulsive Symptoms
Speech Problems
Attention Problems
Hyperactivity
Learning Problems
Conduct Problems or Criminal Behavior
Autism Spectrum
Schizophrenia
Alzheimer's or Dementia