1. GENDER:
2. DATE OF Dx: LOCATION:(City,State)
AGE AT Dx: LOCATION:(City, State)
CURRENT AGE: LOCATION:(City, State)
BIRTH LOCATION:(City,State)
UNUSUAL CIRCUMSTANCES: (Lived one place Dx'd in another location..
(There were
a couple of you who were on
(vacation
or business).
3. CURRENT MEDICATIONS: (Please List)
4. MEDICATIONS TRIED BUT DID NOT WORK FOR YOU.(Please List)
5. IF YOU FEEL THAT YOUR PHYSICIAN/NEUROLOGIST IS
EXPERIENCED WITH TM (or atleast willing to learn) PLEASE
LIST HIM AS SOMEONE YOU WOULD RECOMMEND TO OTHER:
NAME:
SPECIALTY:
HOSPITAL AFFILIATION:
CITY, STATE
TELEPHONE:
6. IF YOU HAVE BEEN TREATED BY A PHYSICIAN/NEUROLOGIST
THAT SHOULD BE AVOIDED AT ALL COSTS BY THOSE WITH
TM:
NAME:
SPECIALTY:
HOSPITAL AFFILIATION:
CITY, STATE
I hope this information will aide many.
Doc