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1266 First Street, Suite 2
Sarasota, FL 34236
(941)957-3366
BrainGain SRQ - Neurofeedback & Brain Light Therapy
1266 First Street, Suite 2 Sarasota, FL 34236
amywarrenlmhc@gMAIL.COM
(941)780-1000
Home
About
Blog
Services
EMDR
Neurofeedback
Brain Light Therapy
Individual Counseling
Intensive Workshops
For Professionals
Contact
Testimonials
Forms
HISTORY FORM
Name
*
First Name
Last Name
Address
*
Birth date
MM
DD
YYYY
Phone
*
(###)
###
####
Please check any conditions or symptoms that apply and include any additional information about onset, length of duration, interventions undertaken or anything you consider important:
General health:
Difficulty falling asleep or staying asleep
Difficulty waking
Restless sleep
Sleepwalking or night terrors
Nightmares
Teeth grinding
Allergies
Asthma
Fatigue
I am always hungry
I am aware of my appetite increasing
I often find myself suddenly aware that I am starving or shaky due to lack of food.
Sense of taste
Thirst awareness
Heat or cold sensitivity
Thyroid disorder
Sense of smell
Skin problems
Low pain threshold
High pain tolerance
Earaches
Bruxism (teeth grinding)
Visual acuity:
Blurred vision
Eye pain
Visual sensitivity to light
Double vision
Blind spots
Poor night vision
Hearing:
Hearing loss
Ringing in ears
Sensitivity to sound
Cardiovascular / pulmonary:
Breathing problems
Heart problems
Hypertension
Palpitations or tachycardia
Gastrointestinal:
Nausea or vomiting
Stomach pain
Intestinal pain
Chronic constipation
Irritable bowel
Crohn's disease
Pain:
Chronic pain or stiffness
Chronic aching pain
Chronic nerve pain (burning or stabbing)
Muscle cramps
Headaches
Neurological:
Migraines
Fainting
Seizures
Speech problems
Tremor or spasticity
Weakness
Balance
Coordination
Accident prone
Motor or vocal tics
Attention and cognitive:
Difficulty with reading comprehension
Difficulty with math
Learning disability
Developmentally delayed
Dyslexia
Poor sense of direction
Difficulty concentrating
Impulsive
Artistic
Difficulty with reading
Poor short-term memory
Poor long-term memory
Urogenital system:
Incontinence
PMS symptoms
Menopausal symptoms
Erectile Dysfunction
Sexual interest
Habits
Coffee use
Alcohol use
Tobacco use
Diet
Other drug use
Behavior / emotions:
Depressed
Anxious
Panic attacks
Difficulty managing emotions
Angry outbursts / aggression
Mood swings
Extreme fears
Unable to sit still
Excessive worry
Short attention span
Difficulty completing tasks
Easily distracted
Forgetful
Poor time management
Trouble multi-tasking
Engage in risky behaviors
Hyperactive
Have you ever been diagnosed with, taken medication for, or think you may have:
Manic-depression
Panic attacks
Phobias
Obsessive-compulsive behaviors
Eating disorders
Addictions
Schizophrenia
Please list any medical or psychiatric diagnosis:
Personal history
Please check any issues which applied and include any additional relevant information.
Early childhood development:
Prenatal stress or injury
Prenatal drug exposure
Difficult labor
Difficult birth
Premature or late birth
Medical problems after birth
Adopted
Sleep problems
Eating problems
Emotional development
Delayed movement and motor skills
Delayed language development
Delayed cognitive or learning skills
Chronic ear infections
Allergies
Asthma
Attachment difficulties
Social skills:
Social anxiety
Difficulty making friends
Lack of empathy
Lack of ability to express feelings
Repetitive daily routines
Takes things very literally
Limited interests
Physical traumas:
Head injury
Concussions
Accidents
Serious illness
CNS infection
Drug overdose
Poisoning
Anoxia
Stroke
High fever
Sports:
Football
Soccer
Boxing
Martial arts
Dance
Baseball
Weight lifting
Track / long distance running
Other
History of trauma & stress:
Abuse or neglect
Family stress
School or job stress
School stress
Recent death in family
Illness
Medical:
List medications, dosage and condition for which prescribed:
List any surgeries or medical procedures:
Please list any other medical or psychiatric diagnoses:
Family history:
Check all that apply and note relationship of family member.
Alcoholism or drug abuse
Asthma
Autoimmune disorders: I Diabetes, Rheumatoid Arthritis Lupus, MS, Scleroderma, etc.
Thyroid disorder
Migraine
Sleep problems
Depression
Sleep problems
Phobias
Manic-depression
Panic attacks
Motor or vocal tics
Seizures
Eating disorders or obesity
Addictions
Obsessive compulsive symptoms
Speech problems
Hyperactivity
Learning problems
Conduct problems or criminal behavior
Autism spectrum
Schizophrenia
Diabetes
Anxiety
Please add any other symptoms or issues which you would like to be addressed:
Thank you!