
	ClinicalQ Report Writer clinicalqreport.com info@clinicalqreport.com

* required field.

ACTIVATION CODE Enter a valid activation code or purchase a new one here

* Code:

SERVICE PROVIDER DETAILS (as you would like it to appear on the report)

* Name of Provider or Clinic:
* Contact Name:
* Email Address (will be used to send report to):

CLIENT DETAILS In order to maintain confidentiality, please use client number only (not name).

* Client ID:
* Gender: Female Male
* Age:
Handedness: Left Right Unknown
ClinicalQ Assessment Date:
Medications:
Symptoms:

CLINICALQ ASSESSMENT DATA Enter the requested EEG data for each location listed below (or use the rapid upload instructions if applicable).

You can place your cursor over each field to see a reminder of which statistic it represents.

LOCATION Cz	LOCATION O1	LOCATIONS F3 and F4	LOCATION Fz
◾CT1:	◾OC1:	◾FF1:	FZ1:
◾CT2:	◾OC2:	◾FF2:	FZ2:
CT3:	OC3:	◾FF3:	FZ3:
CT4:	OC4:	FF4:	FZ4:
◾CT5:	◾OC5:	FF5:
CT6:		FF6:
CT7:		FF7:
		◾FF8:

◾Note for CT1, CT2 and CT5: The value can be positive or negative.
◾Note for OC1, OC2 and OC5: The value can be positive or negative.
◾Note for FF1, FF2, FF3 and FF8: If F4>F3, value is positive; If F4<F3, value is negative.

Include patient values in report

ClinicalQ Assessment Data Enter the requested EEG data for each location listed below.

If using the BFE ClinicalQ and Braindriver software suite, use the BROWSE button below to upload your .csv file. Click TRANSFER DATA TO FORM to populate the fields.

If you are manually entering the data, you can place your cursor over each field to see which statistic it represents. Click here to download/print a list of the statistics required to run the report.

Report cannot be generated yet.

Please fill in all the required fields with valid entries!