New Patient Intake This form is McAfee Secure but it is not HIPAA compliant. Please enable JavaScript in your browser to complete this form. - Step 1 of 5Patient DemographicsPatient Name *FirstLastPatient Date of Birth *Gender *MaleFemaleOtherRather not specifyEmail *Phone number *Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryRelative to contact if unable to speak?Who referred you?If no one, how did you hear about us?Primary PhysicianNextSave and Resume LaterChief ComplaintDescribe what happened.How long ago did the injury occur? *0-2 years2-5 years5-10 years10+ yearsHow severe was the trauma? *Significant trauma (e.g. motor vehicle accident, blunt trauma to head, multiple concussions) Moderate trauma (e.g. fall from less than 8 feet, single sports concussion) Minor trauma or no trauma (e.g. whiplash, emotional trauma, chemical insult, drug side effect)No traumaDid you receive emergency medical care? *Went to the ERStayed overnight at hospitalSurgery was performedNo emergency medical care was requiredWhat were your initial symptoms immediately after the injury? (select all that apply) *HeadacheHead PressureNeck PainNausea or vomitingDizzinessBlurred VisionBalance ProblemsSensitivity to lightSensitivity to soundCraving sweetsLoss of appetiteDecreased libidoFeeling slowed downFeeling like “in a fog”“Don’t feel right”Difficulty concentratingDifficulty rememberingFatigue or low energyConfusionTrouble falling asleep or staying asleepOversleepingMore emotionalDepressionSadnessShame or guiltIrritabilityNervous or anxiousEasily distractedDifficulty making decisionsDifficulty communicating thoughts or feelingsDifficulty taking care of yourselfWhat treatments have been performed? Any improvements since accident?What are your current symptoms? (select all that apply) *HeadacheHead PressureNeck PainNausea or vomitingDizzinessBlurred VisionBalance ProblemsSensitivity to lightSensitivity to soundCraving sweetsLoss of appetiteDecreased libidoFeeling slowed downFeeling like “in a fog”“Don’t feel right”Difficulty concentratingDifficulty rememberingFatigue or low energyConfusionTrouble falling asleep or staying asleepOversleepingMore emotionalDepressionSadnessShame or guiltIrritabilityNervous or anxiousEasily distractedDifficulty making decisionsDifficulty communicating thoughts or feelingsDifficulty taking care of yourselfAny other symptoms?How is your mobility? *Wheelchair requiredRequires assistance walking No assistance needed Are you able to verbally communicate? *Yes, I can speak wellYes, but speaking is difficultI rely on written communicationNo, I cannot speak or write and I require assistanceAre you able to eat on your own? *Yes, I eat independently No, I require assistanceNo, I have a feeding tubeMental Health Conditions: *No mental health history Mental health conditions in family historyPersonal mental health disorderSeeing a psychiatristDo you have a mental health diagnosis (e.g. depression, anxiety, bipolar disorder, schizophrenia)?PreviousNextSave and Resume LaterMedical / Social How many medications are you taking? *012345+List medications and supplements currently taking:Do you have any other medical conditions (other than your primary injury)? *012345+List medical conditions and surgical history:Family Medical HistoryAllergiesAlcohol/Tobacco/Drugs (If so how much?)Diet (typical breakfast, lunch, dinner, snacks) Social (occupation, who you live with)Exercise (how much and what type)Chemical Exposures (if so, what substance) Spiritual (how do you care for your spiritual essence)PreviousNextSave and Resume LaterReview of SystemsHead: Any old head injuries, current headaches, or migraines?Ears: Ringing or discharge? Eyes: Blurred vision, floats, or trouble seeing at night?Mouth: Any root canals or amalgams? Any broken or painful teeth? Regular dentist?Neck: Trouble swallowing, masses, or difficulty moving?Chest: Any chest pain, palpitations, murmurs, or difficulty breathing?GI: Any stomach pain, burning with or without meals? Bowel movements?GU: Urinary urgency, incontinence, painful urination, or discharge? MS: Any pain or decrease range of motion with movement of head, neck, torso, arms, hips, legs, or feet? Skin/Hair/Nails: Hair loss? Skin rash? Cracked nails?Neuro: Any sensation changes in arms and hands? Any trouble gripping objects or prickly feelings while touching objects with hands or feet? Psyche: Do you have frequent mood changes? Do you have a case manager?Health Maintenance: Have you been expose to vaccinations?Other:PreviousNextSave and Resume LaterScheduling with TBI TherapyYour answers will be reviewed by our team and we will follow up with you however you choose below. Before any email, phone, or in-person correspondence, we ask all patients to review the educational webinars offered at tbitherapy.com/webinars. I would like to pay for a(n): *Deposit for in-person consultation visit - $ 75.00In-person consultation at the Basalt, CO location - $ 350.0030-min phone call with a TBI Therapy provider - $ 300.00Baseline Cognitive Assessment Test (includes 5 subsequent scans) - $ 50.00I have 1-2 specific questions that can be answered by email. - $ 0.00I have already arranged payment - $ 0.00Please note we require a $75 deposit to hold appointments for new patients, which will go to towards the cost of the appointment. If an appointment is cancelled in less than 24-hours or patient no-shows, this payment will not be refunded. Payment is due at time of service and is non-refundable. Any additional necessary IV infusions or injection procedures will be paid for at the time of service. We do not submit to insurance.Please write out the 1-2 specific questions or comments you have for a TBI Therapy provider.Custom Captcha * = Square *CardName on CardWebsiteSubmitSave and Resume Later Your form entry has been saved and a unique link has been created which you can access to resume this form. Enter your email address to receive the link via email. Alternatively, you can copy and save the link below. Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted. Copy Link Email * Send Link