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HOME
CONDITIONS
SERVICES
BLOG
ABOUT US

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CONDITIONS
SERVICES
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ABOUT US

INFORMED CONSENT FORM FOR SLEEP PROGRAM

Welcome to our practice. In order to make the most of our time in this initial session, we would appreciate it if you would respond to the questions below. If there are things that do not apply, feel free to leave them blank or respond NA.

Please fill this questionnaire before your Therapeutic Assessment appointment. Thank you.

1. What are your main concerns?

2. Do any blood relatives have psychiatric conditions? If yes, please explain. If No (Skip Question 3)

3. What impact has their mental illness had on your life and your family?

4. Are you originally from BC? If not, please tell us where you grew up.

5. How would you describe your childhood? (Good, difficult, Average) (Please explain)

6. Are you attracted to men, women or both?

7. Do you identify as male, female, nonbinary or other?

8. Are you in a relationship? if yes, for how long?

9. Describe your relationship to your significant other. (if applicable)

10. Do you have any children?

11. Describe your relationship to your parents

12. describe your relationship to your siblings (tell us where you rank in age)

13. How was/is their discipline style?

Authoritarian Authoritative Permissive

14. Please list all your schools and education that you obtained there.

15. Did you enjoy school?

16. Do you have any family or friends as support? If yes, Please explain.

17. Do you feel healthy overall?

Yes No

18. When was your last blood work and what did it show?

19. History of head injuries or concussions? If yes, The severity and grade, and when?

20. Seizures? If yes, Type, Severity and date?

21. Regular Migraine Headaches? With or without aura, any triggers, frequency

22. Neurological conditions (TIAs or stroke)? If yes, when? any treatments? any deficit as a result?

23. Have you had any surgeries in your life? If yes, what surgery and when (date of surgery)

24. Any GI disturbances? (Malabsorption, Irritable Bowel Syndrome, Reflux, Inflammatory bowel disease, Celiac Dz, sensitivity to certain foods, Bloating&gas)

25. Any use of antibiotics?If yes, what? when? for how long?

26. Do you have regular bowel habits? (Any constipation, diarrhea, fatty stools or infrequent bowel movements)

27. Thyroid disease?

28. Heart rhythm problems? Heart disease? Any cholesterol problems? Any cholesterol-reducing medications?

29. High blood pressure?

30. Diabetes?

31. Hormone problems?

32. Fungal growth in the body? Toes? Tongue? Other body parts? (Please explain)

33. Lung conditions?

34. Bladder problems?

35. Problems with sexual functioning?

36. Osteoporosis?

37. Old home? (Before 1960's - Heavy metal toxicity)

38. Family History:

Thyroid Heart diseases High blood pressure Lung problems Bladder problems GI disturbance Osteoporosis Diabetes

39. As a child, did you reach all your developmental milestones (walked and talked on time)?

40. Did you have any separation anxiety issues (meaning your parents could not leave you anywhere such as at preschool or with another family member or friend)?

41. Current Psychiatric medication(s): (Dose, When did you start taking it, Dose changes, Any side effects, Any benefits)

42. Past Psychiatric medication(s): (Dose, When did you start taking it, Dose changes, Any side effects, Any benefits, Why you stopped taking it, When you stopped taking it)

43. Current medication(s): (Dose, When did you start taking it, Dose changes, Any side effects, Any benefits)

44. CURRENT SUPPLEMENT(s): (Who recommended the supplement(s))

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Elumind Centres For Brain Excellence is a private out-patient healthcare centre specializing in optimizing brain functions through various neurotherapeutic modalities. We deliver a comprehensive, personalized case managed collection of holistic therapies that create long-lasting lifestyle changes.

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