See if You Qualify for Treatment for TBI!

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Patient Demographics

Patient Name *

First

Last

Patient Date of Birth *

Gender *

Male
Female
Other
Rather not specify

Email *

Phone number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Relative to contact if unable to speak?

Who referred you?

If no one, how did you hear about us?

Primary Physician

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Chief Complaint

Describe what happened.

How long ago did the injury occur? *

0-2 years
2-5 years
5-10 years
10+ years

How 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 trauma

Did you receive emergency medical care? *

Went to the ER
Stayed overnight at hospital
Surgery was performed
No emergency medical care was required

What were your initial symptoms immediately after the injury? (select all that apply) *

Headache
Head Pressure
Neck Pain
Nausea or vomiting
Dizziness
Blurred Vision
Balance Problems
Sensitivity to light
Sensitivity to sound
Craving sweets
Loss of appetite
Decreased libido
Feeling slowed down
Feeling like “in a fog”
“Don’t feel right”
Difficulty concentrating
Difficulty remembering
Fatigue or low energy
Confusion
Trouble falling asleep or staying asleep
Oversleeping
More emotional
Depression
Sadness
Shame or guilt
Irritability
Nervous or anxious
Easily distracted
Difficulty making decisions
Difficulty communicating thoughts or feelings
Difficulty taking care of yourself

What treatments have been performed? Any improvements since accident?

What are your current symptoms? (select all that apply) *

Headache
Head Pressure
Neck Pain
Nausea or vomiting
Dizziness
Blurred Vision
Balance Problems
Sensitivity to light
Sensitivity to sound
Craving sweets
Loss of appetite
Decreased libido
Feeling slowed down
Feeling like “in a fog”
“Don’t feel right”
Difficulty concentrating
Difficulty remembering
Fatigue or low energy
Confusion
Trouble falling asleep or staying asleep
Oversleeping
More emotional
Depression
Sadness
Shame or guilt
Irritability
Nervous or anxious
Easily distracted
Difficulty making decisions
Difficulty communicating thoughts or feelings
Difficulty taking care of yourself

Any other symptoms?

How is your mobility? *

Wheelchair required
Requires assistance walking
No assistance needed

Are you able to verbally communicate? *

Yes, I can speak well
Yes, but speaking is difficult
I rely on written communication
No, I cannot speak or write and I require assistance

Are you able to eat on your own? *

Yes, I eat independently
No, I require assistance
No, I have a feeding tube

Mental Health Conditions: *

No mental health history
Mental health conditions in family history
Personal mental health disorder
Seeing a psychiatrist

Do you have a mental health diagnosis (e.g. depression, anxiety, bipolar disorder, schizophrenia)?

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Medical / Social

How many medications are you taking? *

List medications and supplements currently taking:

Do you have any other medical conditions (other than your primary injury)? *

List medical conditions and surgical history:

Family Medical History

Allergies

Alcohol/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)

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Review of Systems

Head: 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:

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Scheduling with TBI Therapy

Your 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 - $ 75.00
In-person consultation at the Basalt, CO location - $ 400.00
30-min phone call with a TBI Therapy provider - $ 300.00
Baseline Cognitive Assessment Test (includes 5 subsequent scans) - $ 50.00
I have 1-2 specific questions that can be answered by email. - $ 0.00

Please 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.

Would you like to know more about: (select all that apply)

Stem cells and platelet rich plasma
Hyperbaric oxygen therapy
Cranial osteopathy
Nutritional supplements and dietary guidlines
IV and intranasal therapies
Adjunctive treatments
Brain imaging and mapping

Before corresponding with TBI Therapy, I will review the educational webinars offered at tbitherapy.com/webinars *

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See if You Qualify for Treatment for TBI!

Patient Demographics

Chief Complaint

Medical / Social

Review of Systems

Scheduling with TBI Therapy

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