YOUR PAPERWORK MUST BE RETURNED TO OUR OFFICE 24-HOURS PRIOR TO YOUR SCHEDULED APPOINTMENT OR YOUR APPOINTMENT WILL BE RESCHEDULED.

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1 Welcome to the NeuroPlus Institute for Neurobehavioral conditions. As you embark on your journey in our clinic, there are a few things we want you to know. First of all, we wish to have a maximum positive impact on the life of every patient that walks through our door. Your new patient exam and case review will begin this process so that we may evaluate if you are a candidate for care in our office. Your initial visit will consist of the following: 1. A Brain Map (aka QEEG). This test takes minutes to complete. It involves wearing a cap which contains electrodes which pick up electrical activity in various lobes of the brain. A conductive gel is used so your hair will be messed up. Bring a towel and hat to wear after the testing. DO NOT use any hair product and make sure the hair has been washing within 24 hours without the use of conditioner. 2. Your Brain Map results will be sent to a normative database for comparison and a report will be generated. This takes 24 hours. 3. After your Brain Map you will see Dr. Serpe for neurologic testing and case review. 4. Dr. Serpe will need time to review your report and correlate your testing findings. 5. A second visit will be scheduled to review the test findings and if accepted for care, the care recommendations. 6. IT IS MANDATORY THAT BOTH PARENTS ATTEND THE SECOND VISIT. Our office policy is to reschedule if both parents fail to attend the second visit. We encourage both parents to be at the first visit but it is not mandatory. YOUR PAPERWORK MUST BE RETURNED TO OUR OFFICE 24-HOURS PRIOR TO YOUR SCHEDULED APPOINTMENT OR YOUR APPOINTMENT WILL BE RESCHEDULED. Return by either method: FAX: / drserpedc@gmail.com YOUR RESERVED APPOINTMENT IS: M, T, W, am / pm 651 Amersale Drive, Suite 109, Naperville, IL (630) Dr. Joseph M. Serpe, D.C.

2 Brain Mapping Preparation Checklist The following instructions are for the patient to review and follow before they come in for a Brain Map (QEEG), and will help assure the best results possible. PLEASE PAY ATTENTION to bolded print. 1) Illness ~ If the patient is sick, call to reschedule; even if he/she only has a cold. 2) Sleep ~ The patient should get a good night s sleep before the brain mapping (let us know if you have any sleep problems or disturbances). 3) Hair & Scalp ~ Your hair needs to be clean and dry. It is best to use a Ph neutral detergent shampoo such as Neutrogena Anti- Residue or Suave Clarifying shampoo the night before or the on the day of your scheduled appointment. Wash your hair three times. If you have a hair extensions, toupee, or corn- rows, please remove or be able to remove for your appointment. No chemical treatments may be administered (coloring, perms, relaxers, etc.) within 48 hours before the Brain Mapping. DO NOT use oils, conditioner, mousse, gels, or hairsprays. Make sure your hair is completely dry before coming for the Brain Map. Please bring a comb or brush. 4) Medications ~ If the patient is taking stimulant medication (i.e., ADHD medication), it is preferable to do the Brain Map recording prior to taking your medication for the day. 5) Over the Counter Medications and Supplements ~ Patients should avoid taking any over the counter medication or supplements for three (3) days prior to the Brain Map. This includes medications and supplements such as such as: acetaphetamine (Tylenol), advil (motrin/ibuprofen), aspirin, analgesics, antihistamines/allergy medications (Benedryl, Claratin, Allegra, Zyrtec), cough and cold medicines, herbs, nasal sprays, neutraceuticals (sports drinks, Gator Aid, etc.), food supplements (including amino acids), vitamins, or other similar products. If you have questions please check with us first. 6) Caffeinated Beverages ~ The patient should NOT drink coffee, tea, or caffeinated beverages in the morning of the testing and the patient should NOT drink soft drinks with caffeine in them, i.e., red bull, highly caffeinated soft drinks, for at least 15 hours prior to the Brain Map. The Day of the Brain Map, the patient should: 1) Eat a high protein breakfast. 2) Bring a towel to wipe your hair and a hat (your hair will be messy from the gel) 3) Drink plenty of water the day before the Brain Map recording. 4) Use the restroom to prior to the start of the Brain Map. 5) Nicotine should be avoided 3 hours prior to your session. 6) Bring any medications or supplements you would like to take after your Brain Map is complete. On the day of your QEEG brain map appointment, plan to spend a minimum of 30 minutes in the office. In addition, you will likely need several minutes to fix your hair following your appointment. 651 Amersale Drive, Suite 109, Naperville, IL 60563

3 Neurological History Patient Name SS# Parent/Guardian Name (If a minor) Relationship Address City/State/Zip Home Phone Cell Phone Date of Birth Sex M F Age Address How did you hear about our clinic? Primary health challenge: Severity 0-10 Secondary challenge (if any) Severity 0-10 Medications: Supplements: Please rate the following 0-10 ( 0 = not at all 10 = worst you can imagine ) Anxiety Depression ADD / ADHD Fatigue Mood Swings Anger Learning Disorder Unable to Focus Memory Problems Headaches Ringing in Ears Poor Concentration Do you have family members with any of the above difficulties? Yes N If so, who? Have you had a seizure at any time? Yes No If so, when? Are your eyes sensitive to light? Yes No Have you had any head injuries (diagnosed or undiagnosed?) Yes No If yes, please explain How many Auto Accidents have you been in? (fender benders count) Obsessive Behavior Insomnia (getting to sleep) Insomnia (staying asleep) Difficulty using body parts Please list any other accidents or falls Please list any surgeries What specific behaviors do you hope to see improve or be eliminated? Initial History Onset and Character of Health Complaints Describe your symptoms and where they occur When did the symptoms first occur? Was there any illness, trauma or significant event prior to the onset? If so, please describe What is the nature of the sensations, disabilities or problems that have arisen? Pain/Headaches/Energy or Weight Changes Have you experienced any pain, headaches, fever, energy or weight changes? Please describe If weight change has occurred, was it expected from a diet or exercise program? Duration and Frequency How long do the symptoms last and how often do they occur? Are they recurrent in nature? Course Has your condition or the symptoms changed since the onset of your condition?

4 If so, please describe Aggravating Factors Is there anything that makes your symptoms worse? Is there anything that makes your symptoms better? Do the symptoms occur at a particular time of day, month or year? Are the symptoms aggravated by pressure changes in the thorax or abdomen? Are the symptoms affected by changes in position, such as rising from a sitting position or lying position? Have you received any treatment? If so, what did it involve? 1. General Health History Family History Have any immediate or extended family members suffered from a major or hereditary illness? Have any immediate or extended family members expressed symptoms similar to yours? Accidents/Trauma Please list all past traumas such as motor vehicle accidents, falls, concussions, fractures, etc. Medications / Supplements Please list all past (long term) and present medications Are you taking any vitamins, remedies or supplements? Please list Are you exposed to any chemicals at home or work? Illnesses Are there any current or past illnesses you have experienced? Tests and Imaging What laboratory, imaging or electrodiagnostic procedures have been performed? Operations/Hospitalizations Please list any operations or hospitalizations you have had Nutrition Describe your diet (poor, moderate or good) What are your 3 favorite foods? Do you have any strong cravings for a particular food? 2. Social History Family Life What is your marital status? Do you have any dependants, if so how many? What is your stress level at home (scale 1-10, 10 being highest) 2

5 Recreation What type of recreational activities do you participate in? Do you exercise regularly? How many days per week? Education What is your level of education? Occupation What is your occupation/ job description? Have there been any recent changes at work? Social Drugs Do you smoke? If so, how many packs per day? Do you drink alcohol? If so, how much? 3. Systems History Smell and Taste Have there been any changes to your sense of smell or taste? Have you recently noticed any smells or tastes that don t seem to go away? Vision Have you noticed any cloudiness, haziness, blurring or double vision? Do you have any difficulty in stabilizing your focus? Do you ever experience movement of your visual environment? Do you experience any pain in or around your eyes? Are you sensitive to light in one or both eyes? Hearing Have you ever noticed any changes to your hearing in either ear? Do you find it difficult to listen when there is background noise? Do you experience any ringing or whooshing noises in either ear? Do you experience pain or itchiness in or around your ears? Do you experience a fullness or blocked sensation in either ear? Balance Do you find it difficult to walk in a straight line? Do you tend to deviate more to the right or left when walking? Do you ever feel like you are leaning or falling to one side? Do you feel as though you are spinning or moving when you are still? Have you experienced any nausea or vomiting in the last 6 months? If so, please explain Do you feel light headed or dizzy when looking at moving objects? Do you feel light headed or dizzy when you change your position? Motor Do you have any difficulty with chewing or swallowing your food? Have you noticed any difficulties with speech (e.g. slurring or stuttering)? Have you noticed any clumsiness (e.g. using tools or utensils, or tripping)? Have you noticed any tremors or uncontrollable movements? Have you noticed any stiffness, cramping or twitching anywhere? Have you noticed any weakness or wasting of muscles? Sensory Have you noticed any changes in skin sensitivity anywhere? Have you noticed any unusual sensations anywhere (e.g. tingling, coldness)? Autonomic Have you noticed any changes in saliva or tearing? Have you noticed any changes in sweating on either side of the body? 3

6 Have you noticed any coldness or puffiness in your extremities? Do you feel light headed or dizzy when you change your posture? Do you experience arrhythmia or rapid changes in your heart rate? Do you experience any breathing difficulties? Do you have any problems with digestion or bowel movements? Do you suffer from ulcers or irritability in the GI tract? Do you have any difficulties with initiating or controlling urination? Have you experienced any signs of sexual dysfunction? Mental Have you noticed any changes in decision-making, planning or organization skills? Have you noticed any changes in attention levels or concentration? Have you noticed any changes in behavior, mood, or personality? Have you noticed any changes in your ability to express thoughts or words? Have you noticed any changes in the comprehension of speech or the written word? Have there been any problems with the recognition of people or objects? Have there been any changes with regard to orientation or spatial awareness? Have there been any changes in short or long term memory? Have you experienced any seizures, anxiety or panic attacks? In your own words, please describe the development of this problem you are having, as well as the impact it has on your life. (job, relationships, etc) Initials Initials If after being evaluated and accepted into care and upon my agreement to enter into care, I instruct Dr. Serpe, D.C., to deliver the care that, in his or her professional judgement, can best help me in the restoration of my health. I also understand that the care offered in this practice is based on the best available evidence. I may request a copy of the Privacy Policy and understand it describes how my personal health information is protected and released on my behalf for seeking reimbursement from any involved third parties. Initials Initials I grant permission to be called to confirm or reschedule an appointment and to be sent occasional cards, letters, s or health information to me as an extension of my care in this office. I acknowledge that any insurance I may have is an agreement between the carrier and me and that I am responsible for the payment of any covered or non-covered services I receive. Initials To the best of my ability, the information I have supplied is complete and truthful. I have not misrepresented the presence, severity or cause of my health concern. Signature Date (MM/DD/YYYY) 4

7 Brain Function Assessment Form (BFAF) Name: Age: Sex: Date: Please circle the appropriate number on all questions below. 0 as the least/never to 3 as the most/always. SECTION 1 A decrease in attention span Mental fatigue Difficulty learning new things Difficulty staying focused and concentrating for extended periods of time Experiencing fatigue when reading sooner than in the past Experiencing fatigue when driving sooner than in the past Need for caffeine to stay mentally alert Overall brain function impairs your daily life SECTION 2 Twitching or tremor in your hands and legs when resting Handwriting has gotten smaller and more crowded together A loss of smell to foods Difficulty sleeping or fitful sleep Stiffness in shoulders and hips that goes away when you start to move Constipation Voice has become softer Facial expression that is serious or angry Episodes of dizziness or light-headedness upon standing A hunched over posture when getting up and walking SECTION 4 Reduced function in overall hearing Difficulty understanding language with background or scatter noise Ringing or buzzing in the ear Difficulty comprehending language without perfect pronunciation Difficulty recognizing familiar faces Changes in comprehending the meaning of sentences, written or spoken Difficulty with verbal memory and finding words Difficulty remembering events Difficulty recalling previously learned facts and names Inability to comprehend familiar words when read Difficulty spelling familiar words Monotone, unemotional speech Difficulty understanding the emotions of others when they speak (nonverbal cues) Disinterest in music and a lack of appreciation for melodies Difficulty with long-term memory Memory impairment when doing the basic activities of daily living Difficulty with directions and visual memory Noticeable differences in energy levels throughout the day SECTION 3 Memory loss that impacts daily activities Difficulty planning, problem solving, or working with numbers Difficulty completing daily tasks Confusion about dates, the passage of time, or place Difficulty understanding visual images and spatial relationships (addresses and locations) Difficulty finding words when speaking Misplacement of things and inability to retrace steps Poor judgment and bad decisions Disinterest in hobbies, social activities, or work Personality or mood changes SECTION 5 Difficulty coordinating visual inputs and hand movements, resulting in an inability to efficiently reach for objects Difficulty comprehending written text Floaters or halos in your visual field Dullness of colors in your visual field during different times of the day Difficulty discriminating similar shades of color Datis Kharrazian. All Rights Reserved. SMGEBFAF32(082013) Symptom groups listed on this form are not intended to be used as a diagnosis of any disease or condition.

8 Brain Function Assessment Form (BFAF) Please circle the appropriate number on all questions below. 0 as the least/never to 3 as the most/always. SECTION 6 Difficulty with detailed hand coordination Difficulty with making decisions Difficulty with suppressing socially inappropriate thoughts Socially inappropriate behavior Decisions made based on desires, regardless of the consequences Difficulty planning and organizing daily events Difficulty motivating yourself to start and finish tasks A loss of attention and concentration SECTION 9 A decrease in movement speed Difficulty initiating movement Stiffness in your muscles (not joints) A stooped posture when walking Cramping of your hand when writing SECTION 7 Hypersensitivities to touch or pain Difficulty with spatial awareness when moving, laying back in a chair, or leaning against a wall Frequently bumping into the wall or objects Difficulty with right-left discrimination Handwriting has become sloppier Difficulty with basic math calculations Difficulty finding words for written or verbal communication Difficulty recognizing symbols, words, or letters SECTION 10 Abnormal body movements (such as twitching legs) Desires to flinch, clear your throat, or perform some type of movement Constant nervousness and a restless mind Compulsive behaviors Increased tightness and tone in specific muscles SECTION 8 Difficulty swallowing supplements or large bites of food Bowel motility and movements slow Bloating after meals Dry eyes or dry mouth A racing heart A flutter in the chest or an abnormal heart rhythm Bowel or bladder incontinence, resulting in staining your underwear SECTION 11 Difficulty with balance, or balance that is noticeably worse on one side A need to hold the handrail or watch each step carefully when going down stairs Episodes of dizziness Nausea, car sickness, or seasickness A quick impact after consuming alcohol A slight hand shake when reaching for something Back muscles that tire quickly when standing or walking Chronic neck or back muscle tightness Datis Kharrazian. All Rights Reserved. SMGEBFAF32(082013) Symptom groups listed on this form are not intended to be used as a diagnosis of any disease or condition.

9 Brain Health and Nutrition Assessment Form (BHNAF) Name: Age: Sex: Date: Please circle the appropriate number on all questions below. 0 as the least/never to 3 as the most/always. SECTION 1 Low brain endurance for focus and concentration Cold hands and feet Must exercise or drink coffee to improve brain function Poor nail health Fungal growth on toenails Must wear socks at night Nail beds are white instead of pink The tip of the nose is cold SECTION 5 Dry and unhealthy skin Dandruff or a flaky scalp Consumption of processed foods that are bagged or boxed Consumption of fried foods Difficulty consuming raw nuts or seeds Difficulty consuming fish (not fried) Difficulty consuming olive oil, avocados, flax seed oil, or natural fats SECTION 2 Irritable, nervous, shaky, or light-headed between meals Feel energized after meals Difficulty eating large meals in the morning Energy level drops in the afternoon Crave sugar and sweets in the afternoon Wake up in the middle of the night Difficulty concentrating before eating Depend on coffee to keep going SECTION 6 Difficulty digesting foods Constipation or inconsistent bowel movements Increased bloating or gas Abdominal distention after meals Difficulty digesting protein-rich foods Difficulty digesting starch-rich foods Difficulty digesting fatty or greasy foods Difficulty swallowing supplements or large bites of food Abnormal gag reflex SECTION 3 Fatigue after meals Sugar and sweet cravings after meals Need for a stimulant, such as coffee, after meals SECTION 7 Brain fog (unclear thoughts or concentration) Pain and inflammation Noticeable variations in mental speed Difficulty losing weight Increased frequency of urination Difficulty falling asleep Increased appetite Brain fatigue after meals Brain fatigue after exposure to chemicals, scents, or pollutants Brain fatigue when the body is inflamed SECTION 4 Always have projects and things that need to be done Never have time for yourself Not getting enough sleep or rest Difficulty getting regular exercise Feel that you are not accomplishing your life s purpose SECTION 8 Grain consumption leads to tiredness Grain consumption makes it difficult to focus and concentrate Feel better when bread and grains are avoided Grain consumption causes the development of any symptoms A 100% gluten-free diet 2013 Datis Kharrazian. All Rights Reserved. SMGEBHNAF34(082013) Symptom groups listed on this form are not intended to be used as a diagnosis of any disease or condition.

10 Brain Health and Nutrition Assessment Form (BHNAF) Please circle the appropriate number on all questions below. 0 as the least/never to 3 as the most/always. SECTION 9 A diagnosis of celiac disease, gluten sensitivity, hypothyroidism, or an autoimmune disease Family members who have been diagnosed with an autoimmune disease Family members who have been diagnosed with celiac disease or gluten sensitivity Changes in brain function with stress, poor sleep, or immune activation SECTION 12 A decrease in visual memory (shapes and images) A decrease in verbal memory Occurrence of memory lapses A decrease in creativity A decrease in comprehension Difficulty calculating numbers Difficulty recognizing objects and faces A change in opinion about yourself Slow mental recall SECTION 10 A loss of pleasure in hobbies and interests Feel overwhelmed with ideas to manage Feelings of inner rage or unprovoked anger Feelings of paranoia Feelings of sadness for no reason A loss of enjoyment in life A lack of artistic appreciation Feelings of sadness in overcast weather SECTION 13 A decrease in mental alertness A decrease in mental speed A decrease in concentration quality Slow cognitive processing Impaired mental performance An increase in the ability to be distracted Need coffee or caffeine sources to improve mental function A loss of enthusiasm for favorite activities A loss of enjoyment in favorite foods A loss of enjoyment in friendships and relationships Inability to fall into deep, restful sleep Feelings of dependency on others Feelings of susceptibility to pain SECTION 11 Feelings of worthlessness Feelings of hopelessness Self-destructive thoughts Inability to handle stress Anger and aggression while under stress Feelings of tiredness, even after many hours of sleep A desire to isolate yourself from others An unexplained lack of concern for family and friends An inability to finish tasks Feelings of anger for minor reasons SECTION 14 Feelings of nervousness or panic for no reason Feelings of dread Feelings of a knot in your stomach Feelings of being overwhelmed for no reason Feelings of guilt about everyday decisions A restless mind An inability to turn off the mind when relaxing Disorganized attention Worry over things never thought about before Feelings of inner tension and inner excitability Datis Kharrazian. All Rights Reserved. SMGEBHNAF34(082013) Symptom groups listed on this form are not intended to be used as a diagnosis of any disease or condition.