Head Injury Program Contact Form

Full Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Format: (000) 000-0000.
Current Location*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Have you experienced a head injury or significant impact to the head or body?*

YesNo
Which best describes your experience? (Select all that apply)*

ConcussionRepetitive head impacts (sports, work, military, etc.)Traumatic brain injury (TBI)Whiplash or acceleration–deceleration injuryUnsure / not formally diagnosed
Approximately when did the injury or injuries occur?*

Within the past 6 months6–12 months ago1–3 years agoMore than 3 years agoMultiple injuries over time
Which of the following are you currently experiencing? (Select all that apply)*

Difficulty with attention or concentrationMemory challenges or mental fatigueHeadaches or head pressureSensitivity to light or soundBalance or coordination difficultiesDizziness or lightheadednessSleep disturbancesMood changes (irritability, anxiety, low mood)Reduced physical or mental staminaOther
Have these experiences remained relatively stable, changed over time, or fluctuated?*

StableGradually improvingGradually worseningFluctuating / inconsistent
What treatments, therapies, or protocols have you pursued for Head Injury to date?
Are you currently able to manage daily activities independently?*

YesWith some difficultyNo
Do you have a primary caregiver or a strong support system (family, friends) assisting you? (The sustainability of our program heavily relies on the support structure of our clients)*

YesNo
How soon would you like to connect with our team?*

As soon as possibleWithin the next few daysWithin the next 1–2 weeksI’m just gathering information
Is there anything else you would like us to know about your condition, personal circumstances, or health goals?
How did you hear about us?
Name of referring Practitioner
I would like to receive newsletters and promotional communications from Dr. Goodenowe Perpetual Health.

YesNo
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