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PATIENT IDENTIFICATION. Although all the information you give here is secure through SSL encryption, please be aware that we cannot GUARANTEE privacy. If you prefer, you may complete this form on paper and either mail or fax it to us for security purposes. By completing this form on-line and submitting it upon completion, you are acknowledging and accepting the risk that this information may not be secure.

Please identify the patient who will be receiving neurofeedback. For privacy purposes, please provide the first name of the patient immediately followed by the first letter of the last name. John Smith would then be johns.

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Do you plan to be seen for neurofeedback in our Providence, RI office or in our Cambridge, MA office?

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Below is a list of problems and complaints that people sometimes have in response to stressful life experiences. Please read each one carefully and check the box to indicate how much you have been bothered by that problem in the PAST MONTH.

  Not at all A little bit Moderately Quite a bit Extremely
Repeated disturbing memories, thoughts, or images of a stressful military experience?
Repeated disturbing dreams of a stressful military experience?
Suddenly acting or feeling as is a stressful experience were happening again (as if you were reliving it)?
Feeling very upset when something reminded you of a stressful military experience?
Having physical reactions (e.g. heart pounding, trouble breathing, or sweating) when something reminded you of a stressful military experience?
Avoiding thinking about or talking about a stressful military experience or avoid having feelings related to it?
Avoid activities or situations because they remind you of a stressful military experience?
Trouble remembering important parts of a stressful military experience?
Loss of interest in things you used to enjoy?
Feeling distant or cut off from other people?
Feeling emotionally numb or being unable to have loving feelings for those close to you?
Feeling as if your future will somehow be cut short?
Trouble falling or staying asleep?
Feeling irritable or having angry outbursts?
Having difficulty concentrating?
Being "super alert" or watchful, on guard?
Feeling jumpy or easily startled?

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FOR NDC STAFF ONLY. Any additional information:

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