Headache Freedom Center Web Link We look forward to serving you! Question Title * 1. Address Name Address Address 2 City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Email Address Phone Number Question Title * 2. Please check all that apply.I am currently suffering with: Chronic migraines or other headaches Trigeminal/Occipital Neuralgia or other type of head/face pain Fibromyalgia or other type of full body pain Cluster Headaches Concussion Inflammatory Bowel Disease or IBS Gastroparesis or Esophageal Spasm Depression Tinnitus Other (please specify) Question Title * 3. Regarding the duration of your illness: 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 Question Title * 4. Regarding the severity of your illness: 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) Question Title * 5. Regarding the impact to my quality of life: 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 Question Title * 6. Regarding my location and ability to follow through with treatment: 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 Question Title * 7. Regarding my financial status and ability to cover the costs of my care: 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 Done