Brain Health Assessment PERSONAL INFORMATION Thank you for your interest in brain mapping and your inquiry regarding personal training for your brain. Please check your email inbox to confirm that you have received an email confirmation of your brain map date/time (a 90-minute appointment). Following your brain map, please also schedule a 60-minute appointment at least 2 days following your brain map to receive brain map results and recommendations (this second appointment is included in the brain map fee). To get started, 1. Please complete your on-line personal profile at www.my-newmind.com first. Directions for completing the online information have been emailed to you. If you need assistance, please call (303) 638-0717. 2. After you have completed the online questions, please download this form and fill it out. Bring a hard copy with you to your brain mapping appointment, or scan the completed version and email it to: info@betterbrainbalance.com. We look forward to serving you! Name Date of birth / / Date of map / / Please write a few words describing your situation or listing the primary issues you are experiencing. What would you like to address through the Better Brain program? 1.) 2.) 3.) HEALTH INFORMATION HANDEDNESS LEFT RIGHT (Please circle) OVERALL HEALTH 1. On a scale of 1-10, please rate your current health. 1 2 3 4 5 6 7 8 9 10 (1 being the worst, 5 being average, 10 being the best) 2. At what age did you experience your best health? Best health at yrs 3. Please describe: 4. Do you exercise on a regular basis? YES NO 5. If so, how many days/week? days/wk estimated # minutes of exercise/week 6. Do you usually eat breakfast? YES NO 7. Do you eat most meals? YES NO 8. Do you have any food allergies or sensitivities? YES NO 9. Do you drink plenty of water daily? YES NO
SLEEP 1. Rate the quality of your sleep in the past month. 1 2 3 4 5 6 7 8 9 10 2. At what time do you usually go to bed? am/pm 3. At what time do you rise in the morning? am/pm 4. Are you able to sleep through the night? YES NO 5. If NOT, please describe: 6. Are you able to fall asleep easily most nights? YES NO 7. If NOT, please describe: 8. Do you wake refreshed? YES NO 9. Do you take aids to help you sleep? YES NO 10. If so, please describe (herbs, C-Pap machine, meds, etc) SCREEN TIME 1. Please estimate the number of hours DAILY visually in front of a screen of any type total hours 2. Hours on computer/pc/laptop = hours 3. Hours on tablet = hours 4. Hours on phone screen or talking on the phone, texting, searching web, social media = hours 5. Does your job or occupation require you to be online? YES NO HEAD or NECK INJURY 1. Have you ever injured your head or neck? YES NO 2. Have you ever had a concussion? YES NO 3. If yes, have you suffered more than one concussion? YES NO 4. Have you ever been in an auto, motorcycle or bicycle accident? YES NO 5. Have you ever had a traumatic brain injury (diagnosed or not)? YES NO 6. Are you currently receiving care for this/these injuries? YES NO 7. Please describe any head or neck injuries, thinking back over the years. Consider the childhood, teen years, and adulthood, including home life, sports, accidents, falls, etc. Use a separate sheet or the back side of this page. PHYSICAL HEALTH Please check any health conditions that you currently experience. You may write-in any additional physical problems or issues you have had in the past, and/or that you are experiencing at this time. Date of last physical exam / / Date of last eye exam / / Date of last dental appt / / Date of last blood work-up or laboratory test / / Adrenal/thyroid Diabetes/blood sugar Immune problems/autoimmune Allergies Digestive issues/gut/ibs Muscle problems Fatigue, tiredness Headaches/Migraines Nerve problems problems Hearing problems Hormonal/Sex hormones issues Skin issues Temperature issues (too cold?) Visual problems Other Please describe here: Are you currently seeing a health care provider (Dr, Chiropractor, Naturopath, etc) for any of the above? YES NO
MENTAL/COGNITIVE/EMOTIONAL HEALTH Please check any issues below that you have experienced in the last 30 days. Add any other concerns issues you currently experience or have experienced in the past: Anger/irritability Emotional issues Parkinson s syndrome Anxiety/panic attacks Impulse control/addictions PTSD Attention/focus problems Insomnia/sleep issues Reading/Spelling problems Brain fog/fuzzy thinking Memory concerns Weight control issues Tinnitus/ringing in ears Math difficulty Confidence issues Learning Difficulties (Diagnosis? Y/N) Decision-making problems Other: Please describe here: Are you currently seeing a therapist, counselor, life coach or clergy for any of the above? YES Note: if you would like us to speak with him/her, please complete a Medical Release form. NO Are you interested in further assessing cognitive health or memory issues? YES NO Have you ever been evaluated for cognitive health or memory concerns? YES NO CONTEMPLATIVE and RESTORATIVE HEALTH 1. Do you engage in a regular practice of yoga, prayer, contemplation YES NO 2. Do you regularly spend time in nature (hiking, walking, sitting, skiing?) YES NO 3. Do you engage in creative activities such as art (drawing, painting, sculpture, metalwork or other art) or music (performance or listening)? YES NO 4. In the past, have you regularly included these practices (contemplative YES NO or time in nature, art, music or other restorative types of activities? YES NO 5. If you currently work, do you take time off on a regular basis? YES NO 6. Please describe your favorite activity, place or practice that you currently use to restore mind, body and/or spirit: MEDICATIONS, SUPPLEMENTS & VITAMINS If you haven t previously listed these on our online Personal Profile form, please provide a list of your current medications here (including name, dose, frequency and for what symptom you are taking each). Feel free to use the other side, or bring a separate copy with you. 1. I have listed all medications and supplements on the online form. YES NO 2. I have known medication allergies. YES NO 3. Please list any medication allergies here: SUBSTANCES 7. Do you currently use psychoactive drugs, medication or alcohol to pick yourself up or calm yourself down? YES NO 8. Have you ever used psychoactive drugs, medication or alcohol in the past to pick yourself up or calm yourself? YES NO 9. Are you currently a smoker? YES NO 10. Have you ever been a smoker? YES NO 11. Do you consider your current use of tobacco, alcohol or street drugs a problem? YES NO 12. If yes on any of these substances, circle those currently using.
MOODS & EMOTIONS 1. How would you describe your general emotional state? (A brief sentence or a few words is fine.) 2. Do you feel depressed or anxious in this moment? Depressed Anxious Neither Please circle those that apply. 3. Have you felt depressed or anxious in the past 30 days? Depressed Anxious Neither Please circle those that apply. 4. Are you currently taking medications for this/these conditions? YES NO Please list the name of your medication for this condition here: OTHER CONDITIONS 1. Any history of other mental health conditions in yourself, such as schizophrenia, bi-polar disorder, mania or psychosis? YES NO 2. Any diagnosis of Dementia, Parkinson s, or Alzheimers in yourself? YES NO FAMILY HISTORY OF BRAIN/MENTAL HEALTH 3. Any history of mental health issues in your family? YES NO If yes, which side of the family (mother s, father s, both?) 4. Any history of memory issues in your family of origin? YES NO 5. Any history of learning problems in your family? YES NO 6. Any history of other psychiatric conditions in family members, such as schizophrenia, bi-polar, psychosis, dementia? YES NO 7. Any history of migraines in your family? YES NO 8. Any history of epilepsy or seizures in your family? YES NO COUNSELING & PSYCHOTHERAPY 1. Are you currently working with a psychiatrist, therapist, counselor, or clergy in matters regarding your mental or emotional health? YES NO 2. If yes, please list name of Provider, if desired Note: we will not contact providers unless we have specific instructions from you (in the form of a signed medical release for sharing of information) requesting that we do so. HISTORY OF SEIZURES or LIGHT SENSITIVITY 1. Are you, or have you ever been, sensitive to strobe lights? YES NO 2. Have you ever been diagnosed with migraines? YES NO 3. Are you now, or have your eyes been, sensitive to bright light (sunlight)? YES NO ANYTHING ELSE? Is there anything that you would like to add? Please write additional information here.
Feel free to bring previous medical reports, including laboratory results of neurotransmitter, immune or metabolic factors with you to your brain map appointment. Parent or Guardian of Minor (under 15 years), please complete this section Name of child/minor who is to receive a brain map and/or neurofeedback training Parent/Guardian Name Address City State Zip Do you live with the patient? Yes No Parent home phone Cell