BrainGain SRQ - History form

HISTORY FORM
Name*

First NameLast Name
Address*
Birth date*

MonthDayYear
Email*
example@example.com
Phone*
Please enter a valid phone number.
Please check any conditions or symptoms that apply and include any additional information about onset, length of duration, interventions undertaken or anything you consider important:
General health:

Difficulty falling asleep or staying asleepDifficulty wakingRestless sleepSleepwalking or night terrorsNightmaresTeeth grindingAllergiesAsthmaFatigueI am always hungryI am aware of my appetite increasingI often find myself suddenly aware that I am starving or shaky due to lack of food.Sense of tasteThirst awarenessHeat or cold sensitivityThyroid disorderSense of smellLow pain thresholdHigh pain toleranceEarachesBruxism (teeth grinding)
Include additional information for selected conditions/symptoms in General health:
Visual acuity:

Blurred visionEye painVisual sensitivity to lightDouble visionBlind spotsPoor night vision
Include additional information for selected conditions/symptoms in Visual acuity:
Hearing:

Hearing lossRinging in earsSensitivity to sound
Include additional information for selected conditions/symptoms in Hearing:
Cardiovascular / pulmonary:

Breathing problemsHeart problemsHypertensionPalpitations or tachycardia
Include additional information for selected conditions/symptoms in Cardiovascular / pulmonary:
Gastrointestinal:

Nausea or vomitingStomach painIntestinal painChronic constipationIrritable bowelCrohn's disease
Include additional information for selected conditions/symptoms in Gastrointestinal:
Pain:

Chronic pain or stiffnessChronic aching painChronic nerve pain (burning or stabbing)Muscle crampsHeadachesCrohn's disease
Include additional information for selected conditions/symptoms in Pain:
Neurological:

MigrainesFaintingSeizuresSpeech problemsTremor or spasticityWeaknessBalanceCoordinationAccident proneMotor or vocal ticsCrohn's disease
Include additional information for selected conditions/symptoms in Neurological:
Attention and cognitive:

Difficulty with reading comprehensionDifficulty with mathLearning disabilityDevelopmentally delayedDyslexiaPoor sense of directionDifficulty concentratingImpulsiveArtisticDifficulty with readingPoor short-term memoryPoor long-term memory
Include additional information for selected conditions/symptoms in Attention and cognitive:
Urogenital system:

IncontinencePMS symptomsMenopausal symptomsErectile DysfunctionSexual interest
Include additional information for selected conditions/symptoms in Urogenital system:
Habits:

Coffee useAlcohol useTobacco useDietOther drug use
Include additional information for selected conditions/symptoms in Habits:
Behavior / emotions:

DepressedAnxiousPanic attacksDifficulty managing emotionsAngry outbursts / aggressionMood swingsExtreme fearsUnable to sit stillExcessive worryShort attention spanDifficulty completing tasksEasily distractedForgetfulPoor time managementTrouble multi-taskingEngage in risky behaviorsHyperactive
Include additional information for selected conditions/symptoms in Behavior / emotions:
Have you ever been diagnosed with, taken medication for, or think you may have:

Manic-depressionPanic attacksPhobiasObsessive-compulsive behaviorsEating disordersAddictionsSchizophrenia
Include additional information for selected conditions/symptoms you have been diagnosed with, taken medication for, or think you may have:
Please list any medical or psychiatric diagnosis:
Personal history

Please check any issues which applies and include any additional relevant information.
Early childhood development:

Prenatal stress or injuryPrenatal drug exposureDifficult laborDifficult birthPremature or late birthMedical problems after birthAdoptedSleep problemsEating problemsEmotional developmentDelayed movement and motor skillsDelayed language developmentDelayed cognitive or learning skillsChronic ear infectionsAllergiesAsthmaAttachment difficulties
Include additional information for selected conditions/symptoms in Early childhood development:
Social skills:

Social anxietyDifficulty making friendsLack of empathyLack of ability to express feelingsRepetitive daily routinesTakes things very literallyLimited interests
Include additional information for selected conditions/symptoms in Social skills:
Physical traumas:

Head injuryConcussionsAccidentsSerious illnessCNS infectionDrug overdosePoisoningAnoxiaStrokeHigh fever
Include additional information for selected conditions/symptoms in Physical traumas:
Sports:

FootballSoccerBoxingMartial artsDanceBaseballWeight liftingTrack / long distance runningOther
Include additional information for selected conditions/symptoms in Sports:
History of trauma & stress:

Abuse or neglectFamily stressSchool or job stressSchool stressRecent death in familyIllness
Include additional information for selected conditions/symptoms in History of trauma & stress:
Medical:
List medications, dosage and condition for which prescribed:
List any surgeries or medical procedures:
Family history:
Check all that apply and note relationship of family member.

Alcoholism or drug abuseAsthmaAutoimmune disorders: I Diabetes, Rheumatoid Arthritis Lupus, MS, Scleroderma, etc.Thyroid disorderMigraineSleep problemsDepressionSleep problemsPhobiasManic-depressionPanic attacksMotor or vocal ticsSeizuresEating disorders or obesityAddictionsObsessive compulsive symptomsSpeech problemsHyperactivityLearning problemsConduct problems or criminal behaviorAutism spectrumSchizophreniaDiabetesAnxiety
Note relationship of family member with conditions/symptoms selected in Family history:
Please add any other symptoms or issues which you would like to be addressed:
Should be Empty:

HISTORY FORM

Please check any conditions or symptoms that apply and include any additional information about onset, length of duration, interventions undertaken or anything you consider important: