Patient Flow Sheet Template Page 4
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4If you answered Yes to any question, please provide amplifying information in the space below. This
information, such as approximate date and age when the event occurred and specifics of what occurred, will
assist in the assessment of your unique circumstances in order that we may provide training
recommendations that are tailored to you or your child.
Prenatal and Developmental History: __________________________________________________________
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Medical Conditions and Treatment History: _____________________________________________________
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Trauma History and Treatment of Trauma: ______________________________________________________
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Brain Health and Treatment History of Brain-based problems: ______________________________________
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Brain & Behavior Associates qEEG Patient Flow Sheet
Page 4
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