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Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Chronic migraines or other headaches

Trigeminal Neuralgia or other type of head/face pain

Fibromyalgia or other type of full body pain

Other (please specify)

My condition started very recently and I haven’t seen any doctors about it

My condition started about 6 months ago and I’ve tried a few things to treat it, with some success

My condition has been present for at least a year, and I’ve tried multiple things to help it with limited success

My condition has been present for a long time and despite all of the things I’ve tried, I’m still suffering greatly

My condition is SLIGHT (Tolerable and causing no limitation)

My condition is MODERATE (Tolerable but causing some occasional limitations)

My condition is SEVERE (Causing significant limitations and getting intolerable)

My condition is EXTREME (Causing near constant limitations and definitely intolerable)

My condition doesn’t affect my quality of life much at all

My condition seems to to impact my quality of life, but only from time to time

My condition has definitely been a significant burden on my quality of life

My condition has basically robbed me of any quality of life that I used to have

I do not live in Pennsylvania and I will not be able or willing to travel to a Headache Freedom Center

I do not live in Pennsylvania but I could foresee traveling to a Headache Freedom Center occasionally

I live within a few hours drive and I would be willing to do what it takes to keep regular appointments

I live close enough that weekly visits will not be a problem for me

I have limited financial resources and will be unable to cover the costs of specialized treatment

I have some financial resources available to me, but I’d rather not make the investment in my wellbeing

I might need some assistance covering the costs, but my health is worth it and I really want to get better

I may or may not have strong financial resources, but I am willing to do whatever it takes to get better