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Our Services
Patient Results
About Us
Blog
Contact Us
- Patient Portal
- Schedule Free Consultation

Brain Injury Survey

Brain Injury Survey

Brain Injury Survey

Step 1 of 27

3%

Welcome. This survey will highlight the underlying causes of your symptoms. What is your greatest frustration that you are looking for help with?*

Enter the symptoms or conditions you are looking for information or help with?

Are you experiencing or have you experienced headaches?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced nausea or vomiting?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced struggles with balance, coordination, clumsiness, or walking?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced an inability to remember people, places, or events?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced dizziness, vertigo, or disequilibrium?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced brain fog or confusion?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced sensitivity to light, sound, smell, taste, or touch?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced changes in vision or ability to read?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced trouble finding the right words?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced poor decision making or judgement?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced any difficulty learning and retaining new information?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced any difficulty viewing computer, TV, tablet, or smartphone screens?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced challenges with sleep?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced mood swings, depression, or anxiety?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced any changes in digestion, abdominal comfort, or elimination?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced fatigue or general feelings of weakness?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced difficulty navigating through stores or large spaces?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced struggles with maintaining positive relationships?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced disinterest in life or normally pleasurable activities?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced neck or head pain following a whiplash injury?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced not wanting to be around people?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced an increase in time needed to complete routine tasks?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced disconnection from yourself and others?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced a feeling that no one believes or understands your symptoms?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you willing to do the work necessary to overcome these challenges?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Please enter the following information
Your Name*
Your Email*
Your Phone*
Thank you for taking the first step towards education and healing. We help people find their path back to health every day. Our clinical staff will review your survey and contact with the results. What is your preferred way?*
- Short Call! 🙂
- Email Me! 🙂

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Contact Details

828.708.5274
info@apexbraincenters.com
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600 Julian Ln. STE 650,
Arden, NC 28704

Our approach is one of functional neurology. Through the use of state-of-the-art brain mapping, objective neurological testing, intensive research-based brain training methods, and nutritional intervention, we are able to assess and train the brain to perform at peak condition.

Copyright © 2024 APEX Brain Centers

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