New Client Brain Integration Technique Paperwork New Client Appointment Checklist 5 Complete and submit form below 5 No makeup, perfume, lotions, or deodorants 5 Drink plenty of water prior to your session 5 Do not come hungry; be sure to eat prior to your session These guidelines are in place for your protection and ours, as we strive to serve you to the best of our ability. Please understand the importance of keeping your appointments. We do have a 24 hour cancellation policy that is strictly enforced. Please contact our Client Advocate if you have any questions or need additional information. New Client Form Please enable JavaScript in your browser to complete this form.CLIENT INFORMATION:Name: *Today's Date: *Home Phone Number:Cell Phone Number: *Email: *Best way to reach you:Address: *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeBirthdate: *Age: *Gender:FemaleMaleReferred by:Are you currently a client of The Well of Life Center? *YesNoIf yes, who is your clinician? Occupation: *Employer:Marital Status: *SingleMarriedDivorcedWidowedName of Spouse:List names of children/siblings, age, sex and any concerns in the area below.In Case of Emergency, please contact:Emergency Contact Name: *Emergency Contact Phone Number: *Relationship: *Please provide details if any or all of the following applies to this client:Adopted? *YesNoLives with:MotherFatherBothStepparentLegal GuardianOther:Other explanation:Overall health:ExcellentGoodFairPoorOther:Other explanation:Reason you are here:Previous treatments for this complaint: Other complaints or problems: The following questions are part of the background necessary to evaluate your learning problems. A number of factors involved with the prenatal, birth, and early postnatal periods are sometimes associated with learning difficulties. Please briefly indicate if any of the listed items below apply and note any that are not included in this list.1. Mother of ClientSickness of any kindIf yes, describe:Anything requiring medical attention of any kind during or as a result of pregnancy or birth?If yes, describe:2. Client's BirthAny difficulty in the birthing process? (e.g. cord around neck, posterior presentation, forceps, oxygen problems at birth, baby bluish)If yes, describe:Fetal distress at birth?Comments:Was your baby removed for a period before presentation to you? YesNoIf yes, for how long? Was there a period of extended separation, e.g. premature?YesNoComments:Medical treatment of any kind needed?If yes, describe:Any other problems?If yes, describe:3. Are you currently under the care of a physician, therapist, or other health care professional?YesNoIf yes, please list name(s) and date(s) of last visit: 4. Current medications/drugs being taken: 5. Nutritional supplements you are taking: 6. Do you smoke, drink alcohol, or consume any other substances? If yes, indicate how much.YesNoCigarettes:Alcohol:Other substances:7. Have you suffered any serious childhood diseases, had any operations, or other medical problems? 8. Have you ever been knocked unconscious? If yes, for how long and under what circumstances? 9. Have you ever been in a car accident? If yes, did you get whiplash? (describe)10. Have you ever had an epileptic fit? If yes, describe. 11. Have you ever suffered febrile seizures (high temperature induced fits or seizures), especially between 8 months and 3 years? If yes, describe. 12. Do you suffer from asthma? Taking medication for it? Which and how often? 13. When did you start to crawl? Did you crawl normally - opposite hand and knee - or did you tend to scoot along on your bum or drag/extend one leg? 14. When did you start talking? Was there any verbal language delay? If so, how long? 15. Any household pets or other animals you or your family members are in close contact with? 16. How would you describe your mood on a day-to-day basis? 17. Any other facts or information that you feel are relevant? MEDICAL HISTORYMost recent physical examination: Purpose: Have you ever had an allergic reaction to:aspirin, ibuprofen, acetaminophen, codeine, penicillinerythromycintetracyclinesulfa localanestheticfluoridemetals (nickel, gold, silver)latexother:Other:DO YOU HAVE or HAVE YOU EVER HAD:hospitalization for illness or injuryheart problems, or cardiac stent within the last six monthshistory of infective endocarditisartificial heart valve, repaired heart defect (PFO)pacemaker or implantable defibrillatorartificial prosthesis (heart valve or joints)rheumatic or scarlet feverhigh or low blood pressurea stroke (taking blood thinners)anemia or other blood disorderprolonged bleeding due to a slight cut (INR > 3.5)emphysema, sarcoidosistuberculosisasthmabreathing or sleep problems (i.e. snoring, sinus)kidney diseaseliver diseasejaundicethyroid, parathyroid disease, or calcium deficiencyhormone deficiencyhigh cholesterol or taking statin drugsdiabetesstomach or duodenal ulcerdigestive disorders (i.e. gastric reflux)osteoporosis/osteopenia (i.e. taking bisphosphonates)ArthritisGlaucomacontact lenseshead or neck injuriesepilepsy, convulsions (seizures)neurologic problems (ADD)viral infections and cold soresany lumps or swelling in the mouthhives, skin rash, hay feverSTI/STDhepatitisHIV/AIDStumor; abnormal growthradiation therapychemotherapyemotional problemspsychiatric treatmentantidepressant medicationalcohol/street drug useAre you:presently being treated for any other illnessaware of a change in your health (i.e. fever; new cough)Taking medication for weight management (i.e. fen-ph en)taking dietary supplementsoften exhausted or fatiguedexperiencing frequent headachesa smoker; smoked previously or use smokeless tobaccoconsidered a touchy personoften unhappy or depressedFEMALE - taking birth control pillsFEMALE – pregnantMALE- have prostate disordersCurrent medical treatment, impending surgery, genetic/development delay, or other treatment? List all drugs you are currently taking and their purpose:PLEASE ADVISE IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.BRAIN INTEGRATION TECHNIQUE BEHAVOIRAL CHECKLISTPlease check anything which might apply:Accident proneAllergies (feel tired or hyper-active after eating)ClumsyConstipatedDaydreams excessivelyDifficulty budgeting timeDifficulty concentratingDifficulty focusing eyesDifficulty following directionsDifficulty giving directionsDifficulty telling timeDizziness/vertigo/balance problemsEye strain/rubs eyes a lotFear of s peaking in front of a groupHas trouble remembering directionsHas trouble remembering months of the yearHas trouble remembering namesHas trouble remembering right/leftHas trouble remembering times tableHas trouble differentiating colorsHeadachesImpatient/restlessImpulsiveInappropriate drowsinessLacks confidenceLeave projects incompleteLiesMood swingsLetter/number reversalOver or under activePoor eye hand co-ordinationPoor handwritingPoor organizational skillsPoor reading comprehensionPoor reading skillsPoor balancePoor spellingPoor at sports or rhythmic activitiesRests head on arm while workingShort attention spanSlow in completing workStops in the middle of a gameTest or performance anxietyTimid/shyMathematicsPhobias/fearsExplain:Speech difficultiesExplain:TMJ/OrthodonticsExplain:Other:Explain:Agreement and Release of Liability: *Please click HERE to read our Agreement and Release of Liability. Then, sign by typing your full name in the box above. By signing, you are acknowledging that you have read and accept the terms and conditions of Agreement and Release of Liability.NameSubmit