Name: Brain Health USA
Price range: $

Name *

First

Last

Date of Birth

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Emergency Contact Name

Emergency Contact Phone

What condition(s) are you seeking treatment for at our clinic?

Depression
Post Traumatic Stress Disorder (PTSD)
Obsessive Compulsive Disorder (OCD)
Anxiety
Suicidal Ideation
Chronic Pain
Other

Please describe

Health Information

List any discontinued medications and the corresponding dose*

If none, type "n/a" or "none"

List any current medications and the corresponding dose*

If none, type "n/a" or "none"

Please list any known allergies

If none, type "n/a" or "none"

Please list any surgical procedure(s)s and approximate date(s)

If none, type "n/a" or "none"

Please list any or all anesthesia problems with you or your family members

If none, type "n/a" or "none"

Please list all current or resolved conditions regarding Neurological/Brain conditions (stroke, epilepsy, concussions, etc.)

If none, type "n/a" or "none"

Please list all current or resolved conditions regarding Cardiac/Heart conditions (high blood pressure, heart attack, heart murmur, etc.)

If none, type "n/a" or "none"

Please list all current or resolved conditions regarding Gastro/Liver/Intestinal conditions (crohn's, IBS, hepatitis, etc.)

If none, type "n/a" or "none"

Please list all current or resolved conditions regarding Gastro/Liver/Intestinal conditions (crohn's, IBS, hepatitis, etc.)

If none, type "n/a" or "none"

Please list all current or resolved conditions regarding Endocrinology (Cancer, Diabetes, Thyroid etc.)

If none, type "n/a" or "none"

Please list all current or resolved conditions regarding Renal/Kidney conditions (renal failure, dialysis etc.)

If none, type "n/a" or "none"

Please list all current or resolved conditions regarding Pulmonary/Lung conditions (asthma, COPD, tobacco use, etc.)

If none, type "n/a" or "none"

Please list all current or resolved conditions regarding Orthopedic/Bone conditions (fractures, rheumatoid arthritis, osteo-arthritis etc.)

If none, type "n/a" or "none"

Please list all current or resolved conditions regarding Other conditions (Fibromyalgia, Pain Syndromes, Chronic Pain, Glaucoma etc.)

If none, type "n/a" or "none"

Personal & Lifestyle

Marriage Status

Married
Divorced
Widowed

Children?

Number of People in Your Household and Their Age(s)

Occupation and Employer

Highest Level of Education

List of Hobbies

Do you exercise regularly?

How Many Meals do you Eat per day?

Are you happy with your weight?

When was the last time you drank alcohol, what type and how much?

Are you concerned about your alcoholic intake?

List any non-prescribed and/or illicit drug use

If none, type "n/a" or "none"

In the last year have you drank alcohol or used drugs more than you meant to?

Have you wanted/needed to cut down on your drinking or drug use in the last year?

In the last year have you used alcohol or non-prescription drugs to deal with feelings of frustration or stress?

As a result of drinking or drug use has anything happened in the last year that you wished hadn't happened?

Are you happy with your sex life?

Describe the stressors in your life.

I am not happy with? *

Myself
My Partner
My Health
My Work
My Life History
My Suicide Attempt
Not Applicable

Please check the boxes related to the following conditions for Depression* *

Myself
Mother
Father
Siblings
Significant Other
Not Applicable

Please check the boxes related to the following conditions for PTSD *

Myself
Mother
Father
Siblings
Significant Other
Not Applicable

Please check the boxes related to the following conditions for Schizophrenia *

Myself
Mother
Father
Siblings
Significant Other
Not Applicable

Please check the boxes related to the following conditions for Suicidality *

Myself
Mother
Father
Siblings
Significant Other
Not Applicable

Please check the boxes related to the following conditions for Drug Abuse *

Myself
Mother
Father
Siblings
Significant Other
Not Applicable

Please check the boxes related to the following conditions for Alcohol Abuse *

Myself
Mother
Father
Siblings
Significant Other
Not Applicable

Please add any other pertinent health information below

Do you agree to receive text messages from Brain Health USA? *

We won't be sharing the patient's cell phone to anyone under any circumstances

Katemine intake program

Please answer the questions below

Health Information

Personal & Lifestyle