Brain Wellness Intake Form


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?
Have you received one or more doses of the COVID-19 vaccine?

Within the Past 12 Months

Have you lost consciousness or fainted at any point?
Have you experienced memory loss?
Have you experienced any seizures?
Have you experienced any convulsions (e.g., body muscles contract and relax rapidly and/or repeatedly)?
Have you experienced any periods of dizziness or vertigo?
Have you found yourself disoriented?
Have you experienced any moments of an altered mental state of mind?
Do you suffer from any type of post-traumatic stress (PTSD)?
Would you be willing to undergo a quick 20-minute brain scan?


Have you ever had a brain scan/test?
Have you ever been admitted into the hospital for any neurological-related condition?