Clinic # *

Patient # *

QEEG (Select One) *

Initial
10th Session
20th Session
Other
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Date of Incident if Applicable

Handedness *

Left
Right
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Conditions/Symptoms - On a scale of 1-10 how bad are they affecting you day to day 10 being worst. If not applicable leave blank.

Addiction

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10
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Anxiety

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Concussion

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Learning Disabilities

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Sleep Disturbances

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ADHD/ADD

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Brain Fog

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Depression

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PTSD

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If "Other" List Below

Other

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Hippocampus Labs Patient Protocols *

Peak Performance Patient Protocol

$500

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