See if You Qualify for Treatment for TBI! Please enable JavaScript in your browser to complete this form.Patient Name *FirstLastPatient Date of BirthEmail *Phone number *Location *Relative to contact if unable to speak?Who referred you?If no one, how did you hear about us?How long ago did the accident happen? What happened? Were you in the hospital? Was surgery performed?What were your initial symptoms? What are your current symptoms? (select all that apply)HeadacheHead PressureNeck PainNausea or vomitingDizzinessBlurred VisionBalance ProblemsSensitivity to lightSensitivity to noiseFeeling slowed downFeeling like “in a fog”“Don’t feel right”Difficulty concentratingDifficulty rememberingFatigue or low energyConfusionTrouble falling asleepMore emotionalIrritabilitySadnessNervous or anxiousAny other symptoms?What medications/supplements are you taking?Do you have any allergies? If so, to what drugs or substances?Do you have any other medical history? Any previous surgeries? What treatments have been performed? Any improvements since accident?What questions do you have about the services offered at TBI Therapy?Would you like to know more about: (select all that apply)Stem cells and platelet rich plasmaHyperbaric oxygen therapyCranial osteopathyNutritional supplements and dietary guidlinesIV and intranasal therapiesAdjunctive treatmentsBrain imaging and mappingWould you like to chat with another patient who has used the treatments at TBI Therapy?YesNoWould you like to know what most other patients experience in outcomes from the treatments at TBI Therapy?YesNoAny other questions, comments, or concerns?I understand this form is not HIPAA compliant. *Yes, I understand.Captcha * = PhoneSubmit
