Brain Wellness Intake Form

Allows healthcare professionals to understand several aspects of brain health from patient symptoms in the past 12 months.

Instruction: Please respond with Yes or No to the following questions. If Yes and asked a follow-up question, please give your best answer.

Within the past 12 months:

1Have you lost consciousness or fainted at any point?
2Have you experienced memory loss?
If so, for what length of time?
3Have you experienced any seizures?
4Have you experienced any convulsions (e.g., body muscles contract and relax rapidly and/or repeatedly)?
5Have you experienced any periods of dizziness or vertigo?
If so, what time of day?
6Have you found yourself disoriented?
7Have you experienced any moments of an altered mental state of mind?
8Do you suffer from any type of post-traumatic stress (PTSD)?
9Would you be willing to undergo a quick 20-minute brain scan?
10Have you ever had a brain scan/test?
11Have you ever been admitted into the hospital for any neurological-related condition?

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Steps on how to print your input & results:

1. Fill in the calculator/tool with your values and/or your answer choices and press Calculate.

2. Then you can click on the Print button to open a PDF in a separate window with the inputs and results. You can further save the PDF or print it.

Please note that once you have closed the PDF you need to click on the Calculate button before you try opening it again, otherwise the input and/or results may not appear in the pdf.

The Brain Wellness Intake Form is designed to provide healthcare professionals with quick to assess and sufficiently comprehensive information regarding brain health and neurology as part of their health assessments.

The form consists of 11 items, answerable by Yes or No. These are summarised below:

  • Loss of consciousness;
  • Memory loss;
  • Experience of seizures;
  • Experience of convulsions;
  • Periods of dizziness or vertigo;
  • Disorientation;
  • Altered mental state of mind;
  • Post-traumatic stress disorder (PTSD);
  • Willingness to undergo brain scan;
  • Experience of brain scan;
  • History of neurological-related conditions.

Specialty: Neurology