Brain Wellness Intake Form Name First Last If you answered yes to a question that has a follow-up question, please give your best answer.Have you been diagnosed with COVID-19 within the last nine months? Yes No Have you received one or more doses of the COVID-19 vaccine? Yes No Within the Past 12 MonthsHave you lost consciousness or fainted at any point? Yes No Have you experienced memory loss? Yes No If so, for what length of time? Have you experienced any seizures? Yes No Have you experienced any convulsions (e.g., body muscles contract and relax rapidly and/or repeatedly)? Yes No Have you experienced any periods of dizziness or vertigo? Yes No If so, what time of day? Have you found yourself disoriented? Yes No Have you experienced any moments of an altered mental state of mind? Yes No Do you suffer from any type of post-traumatic stress (PTSD)? Yes No Would you be willing to undergo a quick 20-minute brain scan? Yes No HistoryHave you ever had a brain scan/test? Yes No Have you ever been admitted into the hospital for any neurological-related condition? Yes No
