Neurofeedback Intake

Neurofeedback Intake

Female
About You
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Birth Date: *
Birth Gender:

MaleFemale
Height:
Weight:
Occupation:
Marital Status:

SingleMarriedSeparatedDivorced
Spouse's Name:
How did you hear about us? *
Emergency Contact Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relation to you?
HIPPA Release
This is a confidential record of your medical history and pertinent personal information. The doctor reserves the right to discuss this information with medical and allied health professionals per the informed consent. Copies of this record can only be released by your written authorization. I give Eastern Iowa Health and Wellness Center/Family and Sport Chiropractic/Iowa Wellness Center permission to disclose medical information concerning:

AppointmentsMedical InformationBoth
This information can be released to the following people: (please include names and phone numbers)
Signature

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I authorize Eastern Iowa Health and Wellness Center/Family and Sport Chiropractic to send updates on my treatment/condition to my primary care physician.

YesNo
Primary Care Physician Name:

First NameLast Name
PCP Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
When were you last seen there?
History
Please select the following that pertain to your present health / past medical history:*

AnemiaAsthmaArthritisAllergies/SensitivitiesArtificial JointAtherosclerosisBruise EasilyCancerCarpal Tunnel SyndromeContagious Skin ConditionMononucleosisFrequent Colds & FluDeep Vein Thrombosis/Blood ClotsDiabetesEpilepsyHeadaches/MigrainesHeart ConditionMumpsRheumatoid ArthritisOpen Sores/WoundsNervous DisordersPhlebitisShortness of BreathPregnancyHigh/Low Blood PressureHepatitisFractureHigh CholesterolKidney DiseaseSwollen GlandsSprains/StrainsThyroid ProblemsSyphilisTuberculosisGonorrheaHigh FeversPneumoniaStrokeJaundiceMental IllnessAlcoholismTennis ElbowTMJRheumatic FeverVein ProblemsChicken PoxPolioNervous DisordersHIVSkin RashesInsomniaMultiple SclerosisObesityMeningitisOsteoporosisFibromyalgiaBronchitisNone of the aboveOther
If other is checked, please explain:
If diabetes is checked above, how many years?
Are you a smoker? If yes, what is the frequency?
Do you consume alcohol? If yes, what is the frequency?
Do you consume caffeine? If yes, what is the frequency?
Do you have a pacemaker or defibrillator?
Please check any of the following that have occured in your family (blood relative):*

Heart DiseaseDiabetesOsteoporosisAlzheimer's DiseaseCancerHigh Blood PressureAllergiesAlcoholismAnemiaAsthmaBleeding TendenciesKidney DiseaseMental IllnessObesityStrokeThyroid ProblemsTuberculosisOtherNone Apply
If other is checked, please explain:
Please list any Disease/Illnesses/Surgeries below with dates:
Please list any Allergies (including Medication Allergies) and Reactions below or reply none: *
Please enter the numbers corresponding to any problem area(s):*
Ex: 10, 21, 50
Women's Health
Are you pregnant?*

YesNo
Are you nursing?*

YesNo
Are you taking birth control?*

YesNo
Do you experience painful periods?*

YesNo
Do you have irregular cycles?*

YesNo
Do you have breast implants?*

YesNo
Do you perform a regular self-breast examination?*

YesNo
Do you take hormone replacement therapy (HRT)?*

YesNo
Do you take oral contraceptives?*

YesNo
When was your last PAP/pelvic exam?*

Within the past yearBetween 1-4 yearsGreater than 5 yearsNever had a PAP or pelvic examPrefer not to answer or don't know
What was the date of your last menstrual period? (only answer if still menstruating)*

Within the past month or currentlyWithin the past 1-3 monthsGreater than 3 monthsPostmenopausalHave not yet begun menstruationPrefer not to answer or don't know
Current Health Information
Tell us more about your needs adn desires regarding brain health: How can we help? What are you hoping to address or acheive through our Neurofeedback program? *
How would you rate your current health? (1 = lowest, 10 = highest)*

12345678910
Rate the average quality of sleep you have gotten in the past month: (1 = lowest, 1 = highest)*

12345678910
What time do you go to bed? (please specify am or pm) *
What time do you rise in the morning? (please specify am or pm)*
Are you able to sleep through the morning?*

YesNo
If no, please clarify:
Are you able to sleep through the night?*

YesNo
If no, please clarify:
Are you able to fall asleep easily most nights?*

YesNo
If no, please clarify:
Do you wake up refreshed?*

YesNo
If yes, please describe any exceptions:
Have you ever injured your head or neck?*

YesNo
If yes, please explain the incident and year:
Please describe any head or neck injuries over the years. Please include any injuries from your childhood, teen years, or adulthood. Include home life, sports, accidents, slips/falls, etc:*
Have you ever had a concussion?*

Yes, a single concussionYes, multiple concussionsNone
If yes, please explain the incident(s) and year(s):
Have you ever been in an auto, motorcycle, or bicycle accident?*

YesNo
If yes, please explain the incident(s) and year(s):
Have you ever had a traumatic brain injury?*

YesNo
If yes, please explain the incident(s) and year(s):
Are you currently receiving care for this/these injuries?*

YesNo
If yes, please explain your current treatments:
Please list any chronic medical problems or brain health issues you may have:*
Are you concerned that hormonal imbalance may be contributing to your condition?*

YesNo
How would you describe your general emotional state? *
Please list any symptoms you are experiencing with the corresponding medication, dosage, and frequency. *
Have you previously or do you currently use psychoactive drugs, medications, or alcohol to pick yourself up or calm yourself down?*

Yes I currently doYes i previously haveNo I never have
Do you consider your use of tobacco, alcohol, or street drugs a problem?*

YesNo
If yes, what substances do you have a problem with?
Have you suffered from depression or anxiety? (please select all that apply)*

I am currently depressedI am currently anxiousI have a history of depressionI have a history of anxietyNone Apply
Please mark all of the following you have a history of:*

Learning DifficultiesMemory ProblemsChildhood ADD/ADHDAdult ADD/ADHD
Do you or a family member have a history of other psychiatric conditions, such as schizophrenia, bi-polar disorder, or psychosis? (please select all that apply)*

Yes, in myselfYes, in a family memberNot in myselfNot in a family member
Are you currently working with a psychiatrist, therapist, counselor, or clergy in matters regarding your mental health?*

YesNo
If yes, please list their name(s):
Are you or have you ever been sensitive to lights or strobe lights, had or been diagnosed with migraines, or had epileptic seizures?*

YesNo
If yes, please provide details:
Quality of Life
How have you taken care of your health in the past?*

MedicationsEmergency RoomRoutine MedicalExerciseNutrition/DietHolistic CareVitaminsChiropracticNone of the aboveOther
If other, please explain:
How did the previous method(s) work out for you?*

Bad resultsSome resultsGreat resultsNothing changedDid not get worseDid not work very longStill tryingConfusedNone of the above
How have others been affected by your health condition?*

No one is affectedHaven't noticed any problemsThey tell me to do somethingPeople avoid me
What are you afraid this might be (or beginning) to affect (or will affect)?*

JobKidsFuture abilityMarriageSelf-esteemSleepTimeFinancesFreedomNone of the above
Are there health conditions you are afraid this might turn into?*

Family health problemsHeart diseaseCancerDiabetesArthritisFibromyalgiaDepressionChronic FatigueNeed surgeryNone of the above
How has your health condition affected your job, relationships, finances, family, or other activites? Please give examples:*
What has that cost you? (time, money, happiness, freedom, sleep, promotion, etc.) Give 3 examples:*
What are you most concerned with regarding your problem? *
Where do you see yourself being in the next 1-3 years if this problem is not taken care of? Please be specific:*
What would be different/better without this problem? Please be specific: *
What do you desire most to get from working with us? *
What would that mean to you? *
Other Symptoms
Fatigue:*

NeverMildModerateSevere
Mood Changes (irritability, anxiety/nervousness, depression):*

NeverMildModerateSevere
Decreased Mental Ability (memory loss, confusion, loss of focus):*

NeverMildModerateSevere
Hot Flashes/Night Sweats:*

NeverMildModerateSevere
Weight Gain (bloating, excessive belly fat, inability to lose weight):*

NeverMildModerateSevere
Decreased Sex Drive (vaginal dryness):*

NeverMildModerateSevere
Sleep Problems (can't stay asleep, can't fall asleep):*

NeverMildModerateSevere
Cold Hands & Feet / Always Cold:*

NeverMildModerateSevere
Hair Loss / Breakage:*

NeverMildModerateSevere
Dry Wrinkled Skin:*

NeverMildModerateSevere
What are you interested in getting help with?*

Acne/RosaceaAesthtics (skin care)Anti-AgingBio-Identical HormonesBody SculptingBotoxCellulite ReductionDiastasis RectiDetoxificationEmsculpt NeoFood SensitivitiesHair RegenerationHelp with SleepLaser Hair RemovalLaser Tattoo RemovalLaser Nail Fungus RemovalLight TherapyWeight Loss/Weight ManagementMicro-NeedlingNutritionPain ManagementSexual EnhancementSkin TighteningStem CellsWrinkle ReductionUrinary IncontinenceLeaking of UrineFrequent UrinationNone of the Above
Please bring an up to date medication list with you to your appointment. Please do not bring your actual medications to the clinic, just a list.
Should be Empty: