DO YOU HAVE ANY OF THE FOLLOWING SYMPTOMS? (mark all that apply)

Anxiety

Depression

Nerve pain

Muscle Spasms

Insomnia

Chronic Pain

Irritability

Night terrors

Hypervigilance

None of these

HAVE YOU BEEN PRESCRIBED ANY OF THE FOLLOWING MEDICATIONS? (mark all that apply)

Dicyclomine

Tizanidine

Baclofen

Carbamazepine

Cyclobenzaprine (Flexeril)

Carisoprodol (Soma)

Lyrica (Pregabalin)

Gabapentin

Nurtec

Tripans (Sumatriptan/ Rizatripan/ Zolmitriptan)

Topamax

None of these

DO YOU SUFFER FROM ANY OF THE FOLLOWING CONDITIONS? (mark all that apply)

Cancer

Fibromyalgia

Autism

Multiple Sclerosis

PTSD

Dementia

Alzheimers

Migraines

Endometriosis

Seizures

Epilepsy

Muscular dystrophy

Cerebral Palsy

None of these

DO YOU SUFFER FROM ANY OF THE FOLLOWING CONDITIONS? (mark all that apply)

Tourette's

CRPS

Chiari malformation

Gout

Charcot

Marie Tooth

Neuralgia

Ehlers-Danlos syndrome

POTS

Radiculopathy

MTHFR

Age-related macular degeneration

None of these

PLEASE COMPLETE YOUR INFORMATION TO GET YOUR RESULTS. *

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Last Name

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