CASE STUDY

BRAINMASTER CASE STUDY

CLINICIAN IDENTIFIER, CREDENTIALS, AND DATE OF SUBMISSION

(e.g. “G. L. Smith, Ph.D., BCIA-EEG 3/17/09”)

CASE IDENTIFIER1 (e.g. "abem1")

HISTORY / SYMPTOM HISTORY

(50 - 400 words)

PROCEDURE (TRAINING PROTOCOL, NUMBER OF SESSIONS, CHANGES)

(50 - 400 words)

RESULTS (CLINICAL AND REPORT FROM OTHERS)

(50 - 400 words)

PSYCHOMETRICS (pre- and post- neuropsych, IVA, TOVA, etc.)

BRIEF SUMMARY STATEMENT

(1 or 2 sentences)

ATTACHED GRAPHICS (insert graphics or list filenames (jpg, bmp, gif) below)
(pre- and post- QEEG, summary or trend graphs, etc)

I hereby submit this report as accurate to the best of my knowledge, and give permission
to BrainMaster Technologies, Inc. to report these results along with my identity.

Signed: _________________________________ Date: _____________________

Affiliation: ______________________________ Phone or Email: ________________

1
Case Identifier: Suggested use: use first three letters of last name followed by first letter of first name, and ending in
the number one. If there are individuals from the same family, subsequent referrals are designated by the next integer.
For example,“Matilda Abernathy” would be: abem1. Her brother “Cecil” would be abec2. You may use other, similar
methods that are simple, unique, and preserve confidentiality.

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