drlytel@gmail.com
Adult Assessment Form - Metrowest Neurofeedback
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Adult Assessment Form

    Name: (required)

    Date of Birth (required):

    Age:

    Email (required):

    Address:

    Home Phone:

    Work Phone:

    Cell Phone:

    Occupation:

     

    Marital status:

    GOALS: Please list three goals for neurofeedback training:

    1.

    2.

    3.

    HEALTH HISTORY:

    Sleep

    Difficulty falling asleep or staying asleep

    Difficulty waking

    Restless sleep

    Sleepwalking or night terrors

    Nightmares

    Other sleep problems

    Allergies

    Asthma

    Frequent Illness

    Fatigue

    DERMATOLOGICAL:

    Skin problems

    VISUAL:

    Double vision

    Blurred vision

    Blind spots

    Eye pain

    Visual sensitivity

    AUDITORY / OLFACTORY:

    Hearing loss

    Ringing in ears

    Auditory sensitivity

    Sense of smell

    MOUTH / THROAT:

    Bruxism

    Sense of taste

    CARDIOVASCULAR / PULMONARY:

    Breathing problems

    Heart problems

    Hypertension

    Palpitations or tachicardia

    Nausea or vomiting

    Stomach pain

    Intestinal pain

    Chronic constipation

    Irritable bowel

    ENDOCRINE:

    Appetite awareness

    Thirst

    Sugar sensitivity

    Diabetes

    Heat or cold sensitivity

    Thyroid disorder

    ORTHOPEDIC:

    Chronic pain or stiffness

    Low pain threshold

    High pain tolerance

    Chronic aching pain

    Chronic nerve pain (burning or stabbing)

    NEUROLOGICAL:

    Headaches

    Fainting

    Seizures

    Speech problems

    Tremor or spasticity

    Weakness

    Balance

    Coordination

    Accident prone

    Motor or vocal tics

    ATTENTION AND COGNITIVE:

    Academic strengths and weaknesses

    Reading

    Math

    Art

    Sense of direction

    Concentration / Distractibility

    Memory

    Impulsivity

    Hyperactivity

    GENITOURINARY:

    Incontinence

    PMS symptoms

    Menopausal symptoms

    BEHAVIOR / EMOTIONS:

    Mood swings

    Depression

    Anxiety

    Anger or aggression

    Manic-depression

    Panic attacks

    Phobias

    Obsessive-compulsive

    Eating disorders

    Addictions

    Risk-taking behavior

    PERSONAL HISTORY:

    PERINATAL:

    Prenatal stress or injury

    Prenatal drug exposure

    Difficult labor

    Difficult birth

    Premature or late birth

    Medical problems after birth

    Adopted at age

    GROWTH AND DEVELOPMENT:

    Colic

    Sleep problems

    Eating problems

    Activity level

    Attachment

    Emotional development

    Motor development

    Language development

    Chronic ear infections

    Allergies

    Asthma

    PHYSICAL TRAUMAS:

    Head injury

    Accidents

    High fever

    Serious illness

    CNS infection

    Drug overdose

    Poisoning

    Anoxia

    Stroke

    PSYCHOLOGICAL TRAUMAS AND STRESSES:

    Abuse or neglect

    Family stress

    School or job stress

    Death in family

    Illness

    TREATMENT HISTORY:

    MEDICATIONS:

    Medication

    For Condition

    Dose

    Dates

    MEDICAL TREATMENT:

    Procedure

    For Condition

    Description

    Dates

    PSYCHOLOGICAL THERAPY:

    Therapy

    For Condition

    Therapist

    Dates

    OTHER THERAPY:

    Therapy

    For Condition

    Therapist

    Dates

    FAMILY HISTORY:

    Symptom

    Yes

    No

    Relationship

    Asthma

    Autoimmune Disorders: I Diabetes, Rheumatoid Arthritis Lupus, MS, Scleroderma, etc.

    Thyroid disorder

    Migraine

    Sleep Problems

    Depression

    Manic-depression

    Anxiety

    Phobias

    Panic Attacks

    Motor or Vocal Tics

    Seizures

    Eating Disorders or Obesity

    Addictions

    Obsessive Compulsive Symptoms

    Speech Problems

    Attention Problems

    Hyperactivity

    Learning Problems

    Conduct Problems or Criminal Behavior

    Autism spectrum

    Schizophrenia