Checklist of Concerns (before)

1
Client/patient name* This field is required.
First Name
Last Name
2
Phone Number* This field is required.
Area Code
Phone Number
3
Email* This field is required.
example@example.com
4
Is this your first session?
YESNO
5
If no, where else and when did you receive the same services last?
6
Chief complaint (s):* This field is required.Main reason(s) for requesting services
7
Allergies* This field is required.1=no problem, 10=severe
8
Asthma* This field is required.1=no problem, 10=severe
9
Frequent colds* This field is required.1=no problem, 10=severe
10
Details of Immunity problems (if any):
11
Take a long time to fall asleep* This field is required.1=no problem, 10=severe
12
Wake up at night/can't fall asleep* This field is required.1=no problem, 10=severe
13
Wake up too early (when there's no need to)* This field is required.1=no problem, 10=severe
14
Feel tired when wake up/don't feel rested* This field is required.1=no problem, 10=severe
15
Nightmares* This field is required.1=no problem, 10=severe
16
Wake up and immediately start worrying* This field is required.1=no problem, 10=severe
17
Details of sleep problems (if any):
Huge
Large
Normal
Small
Ok
Ok
18
Shortness of breath/shallow breathing/holding breath* This field is required.1=no problem, 10=severe
19
Dizziness* This field is required.1=no problem, 10=severe
20
Details of lungs/breathing problems (if any):
Huge
Large
Normal
Small
Ok
Ok
21
Bloating or gas* This field is required.1=no problem, 10=severe
22
Irritable bowel* This field is required.1=no problem, 10=severe
23
Constipation* This field is required.1=no problem, 10=severe
24
Diarrhea* This field is required.1=no problem, 10=severe
25
Details of intestines/abdominal problems (if any):
Huge
Large
Normal
Small
Ok
Ok
26
Thyroid problems* This field is required.1=no problem, 10=severe
27
PMS symptoms1=no problem, 10=severe, or n/a
28
Hot flashes1=no problem, 10=severe, or n/a
29
Details of hormone problems (if any):
Huge
Large
Normal
Small
Ok
Ok
30
Pain in muscles/joints* This field is required.1=no problem, 10=severe
31
Fibromyalgia* This field is required.1=no problem, 10=severe
32
Bodily fatigue* This field is required.1=no problem, 10=severe
33
Details of muscle problems (if any):
Huge
Large
Normal
Small
Ok
Ok
34
Headaches* This field is required.1=no problem, 10=severe
35
Migraines* This field is required.1=no problem, 10=severe
36
Seizures* This field is required.1=no problem, 10=severe
37
Short term memory loss* This field is required.1=no problem, 10=severe
38
Long term memory loss* This field is required.1=no problem, 10=severe
39
Blocked on words* This field is required.1=no problem, 10=severe
40
Body or vocal tics* This field is required.1=no problem, 10=severe
41
Details of nervous system problems (if any):
Huge
Large
Normal
Small
Ok
Ok
42
Difficulty concentrating/easily distracted* This field is required.1=no problem, 10=severe
43
Difficulty organizing and/or scheduling* This field is required.1=no problem, 10=severe
44
Difficulty prioritizing tasks* This field is required.1=no problem, 10=severe
45
Losing train of thought* This field is required.1=no problem, 10=severe
46
Hyperactive/can't sit still* This field is required.1=no problem, 10=severe
47
Details of attention/organization problems (if any):
Huge
Large
Normal
Small
Ok
Ok
48
Verbally impulsive* This field is required.1=no problem, 10=severe
49
Inverting numbers/letters* This field is required.1=no problem, 10=severe
50
Dyslexia* This field is required.1=no problem, 10=severe
51
Details of learning problems (if any):
Huge
Large
Normal
Small
Ok
Ok
52
Drink alcohol* This field is required.1=no problem, 10=severe
53
Smoke marijuana* This field is required.1=no problem, 10=severe
54
Smoke cigarettes* This field is required.1=no problem, 10=severe
55
Binge eat* This field is required.1=no problem, 10=severe
56
Eat sweets/carbohydrates* This field is required.1=no problem, 10=severe
57
Don't eat enough* This field is required.1=no problem, 10=severe
58
Drink caffeinated or energy drinks* This field is required.1=no problem, 10=severe
59
Overspend* This field is required.1=no problem, 10=severe
60
Details of habits (if any):
Huge
Large
Normal
Small
Ok
Ok
61
Mood swings* This field is required.1=no problem, 10=severe
62
Feel depressed or down* This field is required.1=no problem, 10=severe
63
Feel worried* This field is required.1=no problem, 10=severe
64
Feel like the world isn't a safe place* This field is required.1=no problem, 10=severe
65
Feel like others are against me* This field is required.1=no problem, 10=severe
66
Feel anxious* This field is required.1=no problem, 10=severe
67
Panic attacks* This field is required.1=no problem, 10=severe
68
Feel hopeless* This field is required.1=no problem, 10=severe
69
Feel numb* This field is required.1=no problem, 10=severe
70
Have repetitive negative thoughts/worries that don't stop * This field is required.1=no problem, 10=severe
71
Need to repeat actions over and over* This field is required.1=no problem, 10=severe
72
Phobias* This field is required.1=no problem, 10=severe
73
Feel angry/angry outbursts* This field is required.1=no problem, 10=severe
74
Feel overwhelmed* This field is required.1=no problem, 10=severe
75
Details of emotions (if any):
Huge
Large
Normal
Small
Ok
Ok
76
Any other issues not mentioned above (if any):
77
Medications:
Huge
Large
Normal
Small
Ok
Ok
78
Head Traumas/Loss of Consciousness:Include when/how long ago and how often
79
How did you hear about Beaverton Neurofeedback (or neurofeedback in general)?
Should be Empty: