Patient Flow Sheet Template printable pdf download

qEEG Patient Flow Sheet

Clinician Information

First, MI, Last name: Juanita F. Jussenhoven, MA

License(s)/Certification(s): LPC Candidate, NCC

Patient Information

Last Name: ________________________________________________________________________________

First Name: ________________________________________________________________________________

Middle Initial: _________________

Patient ID#: ______________ Handedness: Left / Right / Ambi

Date of Birth (mm/dd/yyyy): __________________________________________________________________

Date, time, and place of recording: _____________________________________________________________

Hours of sleep the night prior to the recording: _______________ Was the sleep restful? Yes / No

Are there any current psychiatric diagnoses? Yes / No If yes, what are they? __________________________

__________________________________________________________________________________________

Medications: _______________________________________________________________________________

__________________________________________________________________________________________

Supplements: ______________________________________________________________________________

__________________________________________________________________________________________

Were any of the above taken on the day of the recording? Yes / No

Which?: _________________________

__________________________________________________________________________________________

Is there a history of Head Injury?

Yes / No

If yes, please provide approximate date of the injury, that age of the patient at the time of the injury, the

severity of the injury, and any loss of consciousness: _______________________________________________

__________________________________________________________________________________________

Is there a history of learning disability? Yes / No

If yes, which one(s)? ______________________________

__________________________________________________________________________________________

Brain & Behavior Associates qEEG Patient Flow Sheet

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Patient Flow Sheet Template