Step 1: Contact and Background Details
Are you a current or plan to be a client, of Brainstorm Rehabilitation?
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Please Select
Yes
No
Maybe
Name
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First Name
Last Name
Date of Birth
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Day
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Month
Year
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Gender
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Male
Female
N/A
We appreciate referrals, how did you find out about our clinic?
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Friend
Family member
Google
Yellow pages
Health professional
Facebook
Signage
Other
Step 2 Background health questions
How many diagnoses concussions has the patient had in the past?
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What is your dominant hand?
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Left
Right
Neither ( that is both)
When was the most recent concussion?
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Day
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Year
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How long was the recovery (time to being cleared to return to activities) from the most recent concussion?
Step 3 Details regarding the Head Injury
In relation to the most recent head trauma, what was the date of the incident?
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Day
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Year
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Hour Minutes
Please mark the most relevant answers with regards to your witnessed or observed symptoms at the time?
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Lying motionless
Balance / movement incoordination and difficulty ; stumbling, slow or laboured movements
Disorientation or confusion / an inability to respond appropriately to questions
Vacant or blank look
Facial injury after head trauma
Did you experience memory disturbance?
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Yes
No
Maybe
What symptoms are demonstrated following the head injury - IMMEDIATELY AFTER THE INJURY (Baseline)?
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Rows
None
Mild +
Mild ++
Moderate +
Moderate ++
Severe +
Severe ++
Headache
'Pressure in Head'
Neck pain
Nausea or vomiting
Dizziness
Blurred Vision
Balance Problems
Sensitivity to light
Sensitivity to noice
Feeling slowed down
Feeling like 'in a fog'
'Don't feel right'
Difficulty concentrating
Difficulty remembering
Fatigue or low energy
Confusion
Drowsiness
More emotional
Irritability
Sadness
Nervous or anxious
Trouble falling asleep
Do your symptoms get worse with physical activity?
Do you symptoms get worse with mental activity?
If 100% is feeling perfectly normal, what percent of normal do you feel?
What symptoms are demonstrated following the head injury - CURRENT STATUS AFTER THE INJURY (Post Injury)?
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Rows
None
Mild +
Mild ++
Moderate +
Moderate ++
Severe +
Severe ++
Headache
'Pressure in Head'
Neck pain
Nausea or vomiting
Dizziness
Blurred Vision
Balance Problems
Sensitivity to light
Sensitivity to noice
Feeling slowed down
Feeling like 'in a fog'
'Don't feel right'
Difficulty concentrating
Difficulty remembering
Fatigue or low energy
Confusion
Drowsiness
More emotional
Irritability
Sadness
Nervous or anxious
Trouble falling asleep
Do your symptoms get worse with physical activity?
Do you symptoms get worse with mental activity?
If 100% is feeling perfectly normal, what percent of normal do you feel?
Part A: Section 2
Occupation
If you are currently a school student, where do you go to school?
St Josephs Primary, PM
St Agnes, PM
St Peters, PM
Hasting Primary
Port Macquarie Primary
Tacking Point Primary
Wauchope Primary
St Josephs Primary, Wauchope
SCAS
Other
What level of schooling did or are are you currently up to?
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Primary
Secondary
University or college
Other
If retired or unemployed, what was your previous occupation?
Part B: Medical Health
The following questions cover your general, social health and wellbeing.
Please briefly list all known hospitalisations, falls and injuries, and serious chronic illness?
Have you been treated or diagnosed with...?
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Heart/ Blood vessel disease
High Blood pressure
Diabetes
Stroke
Acquired or Traumatic Brain Injury
Cancer
Chronic Fatigue like disorder
Asthma
Eczema
Aspergers Disorder or Autism Spectrum Disorder
Dyslexia or Sensor Processing Disorder
Not Applicable (N/A)
Other
Currently (within the last 3 months) have you experienced...?
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Unexplained fevers
Night sweats
Unexplained bleeding or fluid discharge
Unexplained weight change
Insomnia or restless sleep
Non specific pain
Not Applicable (N/A)
Other
Have any of your relatives suffered from...?
Diabetes
Heart or Blood Vessel disease
Epilepsy or seizure like events
Uncontrolled movement disorders- like Tourettes or tics
Muscle, bone or joint problems
Cancer
Stroke
Brain or other nervous system disease
Aspergers or other like neurological psychosis
Do you drink alcohol?
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Please Select
No
Standard 0-5 glasses per week
Standard 6-20 glasses per week
Standard more than 20 glasses per week
Do you smoke?
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Please Select
No
Standard 1 packet per week
Standard 2-4 packets per week
Standard more than 5 packets per week
Please briefly list your previous and current drugs and medications.
Part E: Neurological Lateralisation Screen
Complete the table below answering any relevant question.
Please identify the most accurate answer.
Rows
Right
Left
Tremor or uncontrollable hand, leg or facial movements
Weakness or paresis of body limb
Muscle atrophy or wasting
Lack of coordination is more demonstrated
Experience a greater pain
Tearing from the eye
Drooling or wetting below the lip
Stiffness and cramping
Coldness and puffy region of the skin
Privacy and Waiver
Consent: I consent to undergo an examination to determine the cause (s) of the condition with which I attended the centre. The examination may entail photographic or video recordings for inclusion in my records. Further consent will be obtained for any treatment after the examination and an explanation of my specific findings. I accept all financial responsibility for my consultation and therapy (if required). Fees are due at the time of consultation unless agreed in advanced. Insurance policies are an agreement between the insurer and myself (the patient) and are fully responsible for any fees I am unable to claim through a plan. Under the new Privacy Act, all information relative to your case is held in total protected confidence. Your consent will be required to release or exchange information with other providers or parties. Also when appropriate, with your approval, relevant information regarding your case may be sent to other medical or healthcare practitioners for co-management of your condition. Waiver: I as a result of this acknowledge my consent to the performance of the proposed Neurological rehabilitation and chiropractic care Darren J Gray and any other chiropractor working in this centre. I understand that I can withdraw consent at any time. I will have the opportunity to discuss the proposed care with Darren J. Gray. I also acknowledge that I will have had the opportunity to ask questions about the nature, extent and purpose of the proposed chiropractic care and I have been given sufficient time to make a decision giving consent for the care to proceed. Disclaimer: Practitioner Darren J Gray is not a medically trained or registered medical practitioner in Australia. All content presented (clinical, research or theoretical) relating to functional neurology/neuroscience, though sourced from current scientific literature as much as possible, is not meant to convey a medically trained opinion, or specifically, a medical neurologist expert opinion on topics presented. Patients who attend for functional neurology or neuro-rehab services should seek a second opinion from a registered specialist neurologist or medical practitioner, if they wish to do so, before commencing treatment.
I consent and acknowledge that I have read and agree to the above policy statement on
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