Follow-Up Questionnaire

Patient Name *

First

Last

Email *

Phone Number

Headache Pain

Memory

Mental Energy

Concentration

Motivation

Mood Stability

Balance

Sleeping Habits

Ability to Work

Ability to Look at Computer

Relationships

Any other symptoms that have improved or worsened that are not listed above?

What challenges are you still dealing with every day?

Did you use the 10 days of intranasal insulin? Would you like to use more insulin?

Did you use the hyperbaric chamber as prescribed? Or, have you completed 40 hyperbaric treatments already?

How is your diet? Did you maintain a ketogenic diet (with low sugar and carbs)? For how long?

Do you have any questions for Dr. Hughes?

I understand this form is not HIPAA compliant. *