Neurofeedback New Client Forms 

Welcome!

It was a pleasure speaking with you and on behalf of our office I would like to congratulate you on taking the next step toward improved health and wellness!  We believe you are in the right place and have seen many clients obtain fantastic results!

Our team needs time to review your case. In order to serve you to the best of our ability, we do require your paperwork to have been received by us by the due date given to you at the time you made your appointment. Please understand your appointment will be canceled if we do not receive your paperwork to review by the given date.

Please submit back to our office by:
             - Filling out form below OR sending PDF electronically
            - Faxing
 to 262-253-039
            - Scanning and emailing paper copy to: clinic@totalhealthinc.com
            - Mailing them to:  Total Health Nutrition Center Attn: Clinic
                                         N82W15485 Appleton Ave.
                                         Menomonee Falls, WI 53051     

            - Or if you’re local, please drop them off and say hello!


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Address
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Tell us more about your needs and desires regarding brain health.

HEALTH INFORMATION

1. OVERALL HEALTH

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2. SLEEP

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3. HEAD OR NECK INJURY

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4. CHRONIC HEALTH PROBLEMS?

5. HORMONES

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6. MOODS & EMOTIONS

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7. MEDICATIONS, SUPPLEMENTS & VITAMINS

8. SUBSTANCES

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9. ATTENTION & LEARNING

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10. OTHER CONDITIONS

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11. COUNSELING & PSYCHOTHERAPY

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12. SEIZURES OR LIGHT SENSITIVITY?

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13. Is there anything that you would like to add?

Parent or Guardian of Minor, please complete this section