Performance Health, P.A.
PT INTAKE
1.
CLIENT INFORMATION
Name: ___________________________________________________________ Date: __________________
E-Mail: ___________________________________________________________
Age: ____________________________________ Circle: Male or Female
Birth Date: _______________________________________________________
Circle: Single
Married
Engaged
Separated
Divorced
Widowed
Living w/ sig other
If married, length of marriage: _______________ Number of Children: _________________
Home Address: ___________________________________________________________________________
Street
___________________________________________________________________________
City
State
Zip
Home Phone: ______________________________________Is it OK to leave a message? ______
Work Phone: ______________________________________ Is it OK to leave a message? ______
Occupation: ________________________________________
Who referred you here or how did you hear about us? _______________________________
Person to contact in case of emergency: _______________________________________________
Relationship: _____________________________________ Phone: _______________________________
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3.
PRESENTING PROBLEMS (why are you here?) DATES BEGAN:
SEVERITY w/ scale of 1-10 & 10 is worst
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CLIENT GOALS
What are your goals here?
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What would changes look like in life?
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Performance Health, P.A.
How do you expect to benefit from Neurofeedback?
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4.
COUNSELING/ THERAPY/ PSYCHIATRIC TREATMENT HISTORY
Are you currently under another therapists care? ___________________________________
If so, Name: ______________________________________________________________________________
Phone Number: ____________________________________________________________________
Describe purpose: ________________________________________________________________________
Name of Primary Care Physician: _______________________________________________________
Have you had previous treatment under another counselor/ therapist? ___________
How long ago? ____________________________________________________________________________
Describe purpose: ________________________________________________________________________
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5.
CURRENT MEDICAL HISTORY
Primary Physicians Name: ______________________________________________________________
Date of last physical exam: _____________________________________________________________
Are you currently under one or more doctor’s care? ________________
If so, please list purpose: ________________________________________________________________
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6.
CURRENT MEDICATIONS
What medications are
you currently taking?
1. ________________________
2. ________________________
3. ________________________
4. ________________________
5. ________________________
6. ________________________
7. ________________________
Purpose:
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Start Date:
Dose:
How often?
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Who is the prescribing Physician? _____________________________________________________
Are you allergic to any medications? _______________
If yes, which ones? _______________________________________________________________________
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Performance Health, P.A.
Blood pressure: _______________________________________ Pulse: __________________________
7.
HISTORY OF PAST OR CURRENT ILLNESS OR INJURY:
How often & Dates
Allergies __________________________________________________________________________________
Asthma ___________________________________________________________________________________
Cancer ____________________________________________________________________________________
Cardiac or Heart problems _____________________________________________________________
Convulsions ______________________________________________________________________________
Diabetes __________________________________________________________________________________
Epilepsy __________________________________________________________________________________
Headaches _______________________________________________________________________________
Head Concussions _______________________________________________________________________
High or Low Blood Pressure ____________________________________________________________
Hypoglycemia or Hyperglycemia ______________________________________________________
Kidney Disease __________________________________________________________________________
Liver Disease ____________________________________________________________________________
Lung Disease _____________________________________________________________________________
Migraines ________________________________________________________________________________
Schizophrenia ___________________________________________________________________________
Seizures __________________________________________________________________________________
Strokes ___________________________________________________________________________________
Sleep Disorders __________________________________________________________________________
Tuberculosis _____________________________________________________________________________
Ulcers _____________________________________________________________________________________
Other _____________________________________________________________________________________
Major health problems of blood related mother & father:
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Major health problems of blood related grandparents:
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Major health problems of blood related siblings, aunts, uncles, & cousins:
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8.
DRUG & ALCOHOL HISTORY
Current: None _______________ Abuse ________________ Dependence __________________
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Performance Health, P.A.
Substances: ______________________________________________________________________________
Quantity: ________________________________ Frequency: _________________________________
For how long: _______________________________ Date last used: __________________________
# of attempts at sobriety: ___________________________
Do you smoke tobacco? ______________________ Marijuana? ____________________________
Amount: __________________________How long? __________________________________________
Do you use caffeine? _______________ Amount: _______________How long? ______________
Past:
None __________________ Abuse ________________ Dependence ________________
Substances: ______________________________________________________________________________
Quantity: _________________________________ Frequency: _________________________________
For how long: ________________________________ Date last used: _________________________
# of attempts at sobriety: ____________________________
Do you have any previous treatment for drugs or alcohol? (Check all that apply)
_____ Outpatient CD Support
_____Inpatient Psychiatric
_____ Self-help Group
_____ Outpatient Psychiatric (Psychotherapy)
_____ Psychotropic Medication Management
_____ Inpatient CD
_____ None
_____ Other: ______________________________________________________________________________
If any are marked above, please give dates of treatments: __________________________
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List any family members, and their relationship to you, who abuse alcohol &/or
drugs. List substances & when: ________________________________________________________
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9.
FAMILY HISTORY
_____ ETOH abuse/ dependence _____ Suicide attempts
_____ Drug abuse/ dependence
_____ Mood disorders
_____ Other psychiatric problems _____ Emotional abuse
_____ Divorce
If any are marked above, please explain: _____________________________________________
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10.
SELF IMAGE
What is your self-image right now?
Physically: ________________________________________________________________________________
Emotionally: _____________________________________________________________________________
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Performance Health, P.A.
Spiritually: _______________________________________________________________________________
Mentally: _________________________________________________________________________________
Other: _____________________________________________________________________________________
11.
SUICIDAL IDEATION
Have you ever attempted suicide? ___________
If yes, when, how, & why? ______________________________________________________________
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Do you currently have any thoughts of suicide? ____________
If yes, explain: ____________________________________________________________________________
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If yes, do you have a plan and means? ____________
If yes, describe and explain: ____________________________________________________________
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Has anyone in your family committed suicide? _____________
Who, when, how, & why? _______________________________________________________________
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Do you have any thoughts of homicide? _____________
If yes, who? ______________________________________________________________________________
If yes, is there a plan, method, and means? Please describe: ________________________
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12.
FAMILY OF ORIGIN (PARENTS)
Who were you raised by? ______________________________________________________________
(Name? Age? Still Married? Divorced? Where Living? Passed Away? When?
Cause?)
Father: ___________________________________________________________________________________
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Mother: __________________________________________________________________________________
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Performance Health, P.A.
Siblings: __________________________________________________________________________________
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Nature of your relationship with them: _______________________________________________
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13.
CURRENT FAMILY (NOT PARENTS)
Name
Age
Living at home?
Spouse or companion (circle): _________________________________________________________
Child: _____________________________________________________________________________________
Child: _____________________________________________________________________________________
Child: _____________________________________________________________________________________
Other: ____________________________________________________________________________________
Nature of your relationship with them: _______________________________________________
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Please use the back of this page to write in any other important health
considerations you may have.
AGREEMENT
I consent to Neurofeedback Therapy at Performance Health, P.A. and the
software used for Neurofeedback: BrainPaint, Thought Technology, Brain
Master.
I understand that I am financially responsible for payment.
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Print Name of Client
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Date
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Signature of Client (If client is under the age of 18, print name of parents or
guardian and relationship)
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Signature of Parents or Guardian
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