Services & Screenings

Name

Email Address

Phone

Date of Birth

Please share with us your primary concern/s in which you are seeking support. You can also write a narrative below. Concerns or Questions with… Please share with us your primary concern/s in which you are seeking support. You can also write a narrative below. Concerns or Questions with…  Memory Loss or Confusion  Brain Fog or Poor Attention  Feelings of Depression  Feelings of Anxiety  Abnormal Mannerisms or Behavior or Personality Changes  Difficulties with Sleep  Difficulties with completion of Day-to-Day tasks  Living with Dementia, I have a diagnosis  Living with Dementia, A loved one has a diagnosis

Have you/your loved one started assessment with your Primary Care Physician or a Specialist Provider to determine a diagnosis related to your concerns? Have you/your loved one started assessment with your Primary Care Physician or a Specialist Provider to determine a diagnosis related to your concerns? Yes No

Please List your Primary Care Physician and what tests have been completed

If you know your goal of seeing support/evaluation please list it here

Have you been seen by a doctor for any BRAIN conditions listed below Have you been seen by a doctor for any BRAIN conditions listed below Stroke Tumor Seizure Lesion Dementia Delirium Psychosocial Dysfunction Other Neurological Conditions (Parkinson's, MS, ALS...)

Have you been seen by a doctor for any HEART conditions listed below Have you been seen by a doctor for any HEART conditions listed below Heart Disease Atrial Fibrillation Blood Pressure Cholesterol Blood Clotting

Have you been seen by a doctor for any LUNG conditions listed below Have you been seen by a doctor for any LUNG conditions listed below COPD Asthma Allergies

Have you been seen a doctor for any STOMACH conditions listed below Have you been seen a doctor for any STOMACH conditions listed below GERD Ulcers Reflux

Have you been seen by a doctor for any of these OTHER conditions listed below Have you been seen by a doctor for any of these OTHER conditions listed below Liver failure or other condition Kidney failure or other condition Diabetes Cancer

If you have had surgery in the last 2 years please list/date surgical history

Did you have or were you told you had difficulty with Anesthesia? Did you have or were you told you had difficulty with Anesthesia? Yes No

Do you have any of these concerns with your safety at home or with a loved one? Do you have any of these concerns with your safety at home or with a loved one? Recent Falls Behavior Mood Unsafe Choices or Actions

Please tell us YOUR story We would like to get to know you, where you are at on your journey, and how we can join you in that place to help you move forward confidently with the solutions we identify.