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Please complete, and submit, this form in order to receive your neurocognitive test.

Required Information

Sex

Optional Information

*Although optional, we suggest completing this portion of the form as it can aid in the interpretation of your test results as well as the creation of your personalized brain and performance optimization plan.

Head Injury History

Have you ever sustained a head injury or concussion?
Have you ever played football or been involved in combat sports?

Medical History

Do you have a history of any of the following conditions? Please select all that apply.

Psychiatric History

Do you have a history of any of the following conditions? Please select all that apply.

Neuropsychological History

Do you have a history of any of the following? Please select all that apply.
Are you currently experiencing any of the following? Please select all that apply.

Sleep Quality

How would you rate your current sleep quality in general?
Are you currently taking any medications for sleep?
Have you ever had a sleep study?
Please select all that apply to yourself.
Do you use a cpap, bipap, or dental device for sleep apnea?

Additional Information and Goals

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