Brain Wellness Intake Form
Allows healthcare professionals to understand several aspects of brain health from patient symptoms in the past 12 months.
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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;
- Altered mental state of mind;
- Post-traumatic stress disorder (PTSD);
- Willingness to undergo brain scan;
- Experience of brain scan;
- History of neurological-related conditions.