Healing Brainwaves Foundation's New Client Form

Email address *

Today's date *

First and Last Name *

Gender

Female

Male

Nonbinary

Birthday *

Phone Number *

Home Address, with city & zip code *

Emergency Contact (name, relation, number) *

List all medications - including over-the-counter, naturopathic and supplements *

Do you have any family history of - Neurological disorders - Psychological disorders - Psychiatric disorders - Cognitive disorders - Developmental disorders Please provide information on who in your family has been diagnosed with the above and what diagnosis. If none - please write none. *

How many brain injuries have you sustained over your lifetime? A concussion is a brain injury. *

0

1-4

5-10

11-20

21-40

40-100

100+

Describe inciting event(s) surrounding your most recent head injury. - Date of injury - Mechanism (how you were injured) - Presentation (symptoms) - Management (treatments) since the time of injury - Trajectory of care since the injury (how have your symptoms reacted to treatment) *

Any active injury or illnesses, including any current diagnosed or undiagnosed head injury? *

After your recent brain injury, were you able to... *

Go back to the activaty immediately

Go back to the activity a few minutes later

Stopped activity (surfing: went in)

Incapacitated and brought in by safety (Example: water patrol/lifeguard/fellow surfer)

Symptoms of a concussion/brain injury can last as short as a few seconds and can appear immediately or even a few days after a wipeout. Please check any symptoms below that you have experienced anytime after a sports-related crash (example: surfing wipeout)? *

Episodic Headache (a headache that happens 1-14 times a month)

Chronic Nonstop Headache

Migraine

Fatigue

Dizziness

Disoriented

Feeling "out of it"

Nausea

Throwing up

Balance issues

Fainting/syncope

Visual symptoms (blurred vision, double vision, loosing vision, spots in vision etc)

Difficulty falling asleep

Difficulty staying asleep

Anxiety

Depression

Suicidal ideations

Light sensitivity

Noise sensitivity

Difficulty talking

Difficulty thinking

Difficulty holding eye contact

Short term memory issues

Long term memory issues

Struggling with concentration

Acquired dyslexia - reading difficulty did not exist previously or to the same extent before injury

Epilepsy/seizures

Please share information on your current symptoms. Rate any of the following symptoms to your current state (0 None, 1-2 Mild, 3-4 Moderate, 5-6 Severe). *

	0	1	2	3	4	5	6
Headache
Pressure in the head
Neck pain
Nausea or vomiting
Dizziness
Blurred vision
Balance problems
Sensitivity to light
Sensitivity to noise
Feeling slowed down
Feeling like "in a fog"
Difficulty concentrating
Difficulty remembering
Fatigue or low energy
Confusion
Drowsiness
More emotional
Irritability
Sadness
Nervous or anxious
Sleep disturbance
Abnormal heart rate
Excessive sweating
Cognitive deficient
Acquired dyslexia - reading difficulty did not exist previously or to the same extent before injury

Do symptoms worsen with physical activity? *

Do symptoms worsen with cognitive (thinking) activity? *

Over the last 2 weeks, how often have you been bothered by any of the following problems? *

	Not at all (0)	Several days (1)	More than half the days (2)	Nearly every day (3)
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it's hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen

Over the last 2 weeks, how often have you been bothered by any of the following problems? *

	Not at all (0)	Several days (1)	More than half the days (2)	Nearly every day (3)
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless

During the past week, how many hours of actual sleep did you get a night? (This may be different than the number of hours you spent in bed) *

5-6 hours (4)

6-7 hours (3)

7-8 hours (2)

8-9 hours (1)

More than 9 hours (0)

Have you experienced any of the following? *

	Yes	No
Cognition has decreased over the years (i.e. difficulty with word recall, memory problems, etc.
Substance abuse (i.e. alcohol, marijuana, stimulants, other depressants, etc.)
Difficulty maintaining healthy relationships (platonic or romantic)
Difficulty controlling emotions (i.e. outbursts of anger, excessive crying, etc.)
Suidical ideations

Have you been diagnosed with any of the following? *

Learning differences (Dyslexia, ADHD, or ADD)

Lyme Disease or/and any co-infections

Long Covid - Covid symptoms lasting longer than 3 months

One or more autoimmune disease

Hormone disorder

Neurological disorder

Psychiatric or Psychological disorder

Nervous system disorder

Cancer

None

If yes to any of the above, please provide more information

Please answer these lifestyle questions. Your answers are confidential. *

	Mulitiple times a day	Daily	Weekly	Monthly	Never
Alcohol use
Marijuana use
Nicotine use
Caffeine use (i.e. coffee, energy drinks, etc.)
Eats processed sugar regularly (i.e. cookies, sweet cereals, etc.)
Use of any controlled substance use not listed above (i.e. stimulants, depressants, etc.)

Have you done any brain injury treatments before? If so, include what you did, when, and what doctor oversaw your care.

HBOT costs $150 per dive. We are here to support access to this modality. Our pricing is as follows. Please select the type you *

HBOT recipient single dive: $140

Package of 10: $900

HBOT Grant Program - must complete a separate application -> found on HBOT program page

HBOT deployment (Veteran events, Mavericks, Rodeo etc)

Other

How did you hear about Healing Brainwaves? *

I understand that the Healing Brainwaves Foundation (“the Foundation”) is a nonprofit organization and not a licensed medical provider. The Foundation does not diagnose, prescribe, or provide medical treatment. I understand and acknowledge the possible risks and side effects of hyperbaric oxygen therapy, which may include but are not limited to: • Barotrauma (ear or sinus pain): I may experience discomfort if I am unable to equalize pressure in my ears or sinuses. Remedies will be provided if needed. • Cerebral Air Embolism and Pneumothorax: A rapid pressure change could, in rare cases, cause air to escape from the lungs into the bloodstream or chest cavity. To minimize this risk, only slow decompression techniques will be used. • Temporary vision improvement (Presbyopia): I may experience temporary improvement in near vision. I understand this effect is typically temporary and that vision usually returns to normal within six weeks after the end of treatment. I will not be fitted for new eyewear prescriptions during this period. • Serous Otitis (fluid in the ears): Fluid may build up due to high oxygen concentrations, but typically resolves after treatment and may be relieved with decongestants. I understand that I am NOT to smoke for the duration of my treatment plan. I understand that no guarantees or assurances have been made regarding the outcome of my therapy. I authorize the Healing Brainwaves Foundation to take photographs for documentation, education, or publication purposes. I understand that my identity will be protected and that I will not be personally identified. I also consent to the release or disclosure of relevant medical information to regulatory agencies or other healthcare providers, as needed for evaluation, accreditation, or treatment coordination. I understand that I am undergoing hyperbaric treatment voluntarily and at my own risk. I hereby give full authorization and consent to the performance of hyperbaric oxygen therapy by the Healing Brainwaves Foundation and its designated medical personnel. *

Please keep in mind that HBOT is considered safe and well-tolerated by most people. There are a few health conditions and exclusions to be aware of: - Untreated pneumothorax (collapsed lung) - Current upper respiratory infections, cold, or flu - Severe chronic obstructive pulmonary disease (COPD) - Uncontrolled seizure disorders - Recent ear surgery or trauma (due to pressure sensitivity) - High fever - Pregnancy (precautionary) - Specific chemotherapy or medication sensitivities We strongly recommend consulting with your physician if you’re unsure about your eligibility. *

Your next step will be to schedule your complimentary brain health meeting with our director, Audrey Lambidakis. This is mandatory for all participants unless you are part of the mobile program. If you are in the acute phase of injury (your concussion was within the last week) and there are no available slots open, please contact her directly. Instructions will be provided on the following page once you submit this form. You will also purchase your HBOT dives before arriving at the clinic. Please have your card ready during your intake appointment if you wish to be a part of our HBOT program. *