Oregon Natural Medicine LENS Intake Form. Gender: F M DOB: / / Age: Address: City:

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1 Oregon Natural Medicine LENS Intake Form Basic info Last Name: First Name: M.I.: Gender: F M DOB: / / Age: Address: City: State: Zip: Home Phone:( ) Cell Phone:( ) How did you hear about LENS neurofeedback? Primary care doctor and phone. Most Prominent Concerns List ALL blows to your head: falls, ALL car accidents, sports and minor bumps. Date How were you functioning before these problems began, and what job or skills have you lost? Current medications and drugs, dosage (if known), reasons for taking them, and their effects? How will you know you are done with treatment? Page 1

2 Constitutional Health Questionnaire Everyone is unique. To help determine the best dosage of LENS training, please rate the following statements by how frequently you are bothered by them: Body Receptivity Frequency from 0-10 (0=never, 10=always) 1. I can feel inside me when the weather is about to change 2. I have allergies or problems eating some foods, like 3. I detect smoking, perfume, mold, bad lighting, etc. before others 4. My body is delicate and sensitive to changes 5. I am bothered by smells, lights or temperatures that others seem not to notice 6. I can feel myself fighting off a cold or flu prior to having actual symptoms 7. My internal motor idles at high speed 8. I am bothered by experiencing other people s emotions in my body 9. I respond strongly to a lower than usual dosage of medicine or herbs 10. I have abilities that some people consider psychic 11. Cloudy weather gets me down 12. I know quickly when something is going to work out, such as a job or relationship Reactivity 1. I have strong reactions to some: Weather changes Foods or medications Smells, sounds or lights 2. I have an explosive temper 3. I can be shocked by my reactions 4. My friends/family sometimes find me difficult to be around 5. I react strongly to unpleasant situations 6. I have strong, unpleasant reactions to skipping meals 7. I have had (circle) seizures, tics, migraines or stroke Year of onset: Hardiness 1. I have strong physical energy or stamina 2. I am known for perseverance and fortitude 3. I have great endurance or can work long hours 4. I can take any medication(s) 5. It takes a lot to upset me internally 6. I keep working or exercising in spite of pain 7. When life hits me hard, I recover quickly 8. I easily tolerate difficult situations 9. I recover faster from a cold than most people 10. I inherited or developed strong constitutional vitality 11. I work out at least once a week Page 2

3 The CNS Functioning Assessment Are you able to drive a motor vehicle? Yes Partially No Are you able to work or study? Yes Partially No Are you able to sustain a close relationship with someone? Yes Partially No Below is a list of problems. How frequently are you currently bothered by them? Please pick a number from 0 to means Not at all, and 10 means All the time. If one or more of your parents had this, place an x in the column listed as Parents? If the problem came on suddenly, put an x in the column listed as Suddenly? Sensory Frequency (0-10) Parents? Suddenly? Light, in general, or lights, bother you Problems with the sense of smell Problems with vision Problems with hearing Problems with the sense of touch Emotions Problems of sudden, unexplained changes in mood Problems of sudden, unexplained fearfulness Problems of unexplained spells of depression Problems of unexplained spells of elation Problems with explosiveness Problems with suicidal thoughts or actions Clarity Feel foggy and have problems with clarity Problems following conversations (with good hearing) Problems with confusion Problems following what you are reading Page 3

4 Realize you have no idea what you have been reading Problems with concentration Problems with attention Problems with sequencing Problems with prioritizing Problems not finishing what you start Problems organizing your room, office, paperwork You cover up that you don't know what was said or asked of you Energy Problems with stamina Fatigue during the day Trouble sleeping at night Problems awakening at night Problems falling asleep again Activation or Anxiety Restlessness Problems with irritability Day Dreaming Worrying Always moving Cold hands or feet Palpitations Page 4

5 Memory Forget what you have just heard Forget what you are doing, what you need to do Problems with procrastination and lack of initiative Problems not learning from experience Pain Head pain that is steady Head pain that is throbbing Shoulder and neck pain Wrist pain Tender areas of muscles All-over pain Joint pain Other pain (specify) Page 5

6 Low Energy Neurofeedback System (LENS) Consent To Treatment Areas of Applicability: The LENS has been successfully applied to central nervous system functions problems, such as symptoms of traumatic brain injury, stroke rehabilitation, fibromyalgia, depression and other mood and anxiety disorders, attention, hyper-activity, explosiveness/anger, and learning problems. Controlled studies on the LENS have been and are being conducted. Several university and medical human subjects review committees have reviewed the LENS treatment and have found it to be minimally invasive. Effects of LENS: The LENS tends to make functioning clearer and easier. It has increased cognitive functioning (memory, concentration, attention, ability to learn and to read, organizing, and sequencing), motivation (initiating and completing activities), and motor skills (coordination, balance, recovery from paralysis). It has elevated mood as an antidepressant. It has improved sleep at night, and reduced sleepiness during the day. It has increased energy and stamina. It has reduced seizures, explosiveness, irritability, spasticity, and background anxiety. It has reduced the symptoms of migraine and fibromyalgia pain, as well as restless leg problems. Side Effects: The side effects sometimes seen with the LENS include feeling fatigued or sleepy following a treatment session, as well as the potential for temporary increases of the symptoms you already have. If you experience any side effects, let Dr. Reive-Schmidt know so that she can work closely with you to adjust the dosage as needed. Other Treatments: Other forms of neurofeedback can have roughly the same effects and side effects as the LENS. No comparative studies have been conducted to permit objective evaluation of which is better, and under what conditions. Discontinuing Treatment: You may discontinue treatment at any time for any reason. Should you wish to discontinue treatment, please inform Dr. Reive-Schmidt. Privacy: Your treatment records are private to the fullest extent of the law; that is, except in cases of potential harm to yourself or to others, or in civil or criminal proceedings and with a court order. Because people are individuals, success with the LENS is best predicted with a complete evaluation and the development of a treatment plan. The evaluation allows Dr. Reive-Schmidt to predict which symptoms will respond, and which may respond first. And, as with any treatment, there can be no guarantee of success in any particular instance. You are therefore invited to consent to be treated on the basis of this information. Before you give your consent to be treated, Dr. Reive-Schmidt wants you to ask as many questions as are necessary for you to understand the process. Please continue to express your questions, observations, and concerns at any time during the treatment process. Consent to Treatment: I have been informed of the potential effects, side effects, benefits, and risks of this treatment, and give my consent to participate in it. / Patient name (Please print. Include parent/guardian name if patient is a minor) Patient signature (Parent/guardian signature if patient is a minor) / / Date Page 6

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