Alpha Stim Questionaire Alpha-Stim Session Questionnaire DateClient First NameClient Last NameDo you suffer from pain?- Select -YesNoDo you suffer from anxiety?- Select -YesNoDo you have insomnia?- Select -YesNoPreviousNextContraindications.Do you have any implanted device?- Select -YesNoDo you have any metal implants?- Select -YesNoDo you Suffer from Drug or Alcohol Addiction?- Select -YesNoAre you pregnant?- Select -YesNoDo you suffer from seizures?- Select -YesNoDo you suffer from Vertigo?- Select -YesNoRefer for Alpha Stim treatment- Select -YesNoNoteProvider’s First NameProvider’s Last Name Previous Submit Form
