Name:

(Please keep answers brief and concise)

What type of headaches do you suffer?


How long have you suffered from neck pain or headaches?


How frequently do you suffer from this?


What is your average level of pain? (1=least)
1 2 3 4 5 6 7 8 9 10

What treatments have you tried?


What affect does this condition have on your quality of life?


What is your level of 17_commitment to finding and correcting the cause of your headaches? (1=least)
1 2 3 4 5 6 7 8 9 10
(Level 5 or above is interpreted as a sincere request for assistance and we will communicate with you)

Email:
Occupation:
Address:
City:
State/Province:
Zipcode:
Daytime Phone:
Nighttime Phone:
Best time to call:
Morning
Afternoon
Evening