Brain Restore Program New Patient Paperwork

Please note: For the best user experience on mobile devices, switch your phone to landscape mode. This form is easiest to complete on a computer.

Patient Full Name

First NameLast Name

Date of Birth

Date

Sex

Marital Status

Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Phone Number (Primary)

Please enter a valid phone number.Format: (000) 000-0000.

Phone Number (Secondary)

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Preferred Contact Method

Emergency Contact Name

Emergency Contact Phone

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact Relationship

Reason for Today’s Visit / Chief Complaint

When did this problem begin?

Please describe your main issues.

List any other doctors or providers you have seen for this condition

Please list any current medications

Are you on a statin?

Please list any vitamins/supplements you are taking

Past Surgeries

Serious Illnesses / Hospitalizations

Do you have any allergies to medications?

If yes, please list medication allergies

How did you hear about Brain Restore Program?

Consent to Examination and Brain Restore Program Treatment

Patient Initials – Consent to Treat

Media Release Form Consent

Date – Consent to Treat

Date

HIPAA / Notice of Privacy Practices Acknowledgment

Financial Policy Acknowledgment

Patient Initials – HIPAA

Patient Initials – Financial Policy

Date – Financial Policy and HIPAA

Date

Please Note: At the end of each section, total the numbers associated with your selected responses. (Example: If you select “Constant” 5 times in the Memory section, your total will be 25.) At the end of the form, add all section totals together to calculate your final score.

Memory

Rows	No Problem 0	Seldom 1	Occasional 2	Frequent 3	Constant 4
Difficulty remembering what you read or heard a few minutes ago
Difficulty recalling events from earlier in the day
Difficulty remembering names of people you’ve recently met
Difficulty finding the right words when speaking
Misplacing everyday items (keys, phone, wallet)

You score for this section:

Focus & Attention

Rows	No Problem 0	Seldom 1	Occasional 2	Frequent 3	Constant 4
Mind wandering or inability to stay on task
Losing track during conversations
Getting easily sidetracked before finishing tasks
Difficulty reading a full page and absorbing the content
Trouble focusing in environments with background noise

You score for this section:

Processing Speed & Mental Clarity

Rows	No Problem 0	Seldom 1	Occasional 2	Frequent 3	Constant 4
Feeling foggy, cloudy, or mentally “not sharp”
Difficulty making decisions or unusual hesitation
Slowness in processing new information
Trouble with mental tasks (math, planning, problem-solving)
Feeling mentally detached or “not fully present”

You score for this section:

Mood & Emotional Regulation

Rows	No Problem 0	Seldom 1	Occasional 2	Frequent 3	Constant 4
Mood swings or emotional reactions that feel out of proportion
Loss of motivation or interest in things you normally enjoy
Feeling overwhelmed by stress that you used to handle
Persistent feelings of sadness, worry, or negativity
Irritability or short temper over minor things

You score for this section:

Sleep Quality

Rows	No Problem 0	Seldom 1	Occasional 2	Frequent 3	Constant 4
Difficulty falling asleep at night
Waking frequently during the night
Waking up feeling unrefreshed or unrested
Sleep that feels light or unrestorative
Irregular or unpredictable sleep schedule

You score for this section:

Energy & Fatigue

Rows	No Problem 0	Seldom 1	Occasional 2	Frequent 3	Constant 4
Not having enough energy for your normal daily routine
Feeling mentally sluggish or drowsy during the day
Hitting a wall of exhaustion before the day is over
Slow recovery after physical or mental effort
Relying on caffeine or stimulants to get through the day

You score for this section:

Sensory & Physical Symptoms

Rows	No Problem 0	Seldom 1	Occasional 2	Frequent 3	Constant 4
Recurring headaches or head pressure
Sensitivity to light (screens, sunlight, fluorescent lights)
Sensitivity to sound (noise feels louder or more irritating than it should)
Feeling unsteady, off-balance, or dizzy
Lightheadedness or vertigo

You score for this section:

Daily Function & Independence

Rows	No Problem 0	Seldom 1	Occasional 2	Frequent 3	Constant 4
Difficulty performing your work or daily responsibilities at your usual level
Discomfort or anxiety while driving or navigating busy environments
Pulling back from social activities or relationships
Difficulty handling new, complex, or unexpected situations
A general sense that your brain isn’t working the way it should

You score for this section:

Survey Score

Rows	Score (Out of 20)
1. Memory
2. Focus & Attention
3. Processing Speed & Mental Clarity
4. Mood & Emotional Regulation
5. Sleep Quality
6. Energy & Fatigue
7. Sensory& Physical Symptoms
8. Daily Function & Independence
TOTAL SCORE: