Initial Questionnaire | HOW Foundation of South Florida

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Initial Questionnaire

Fill out our short questionnaire below and a member of our team will get in touch with you to discuss ways we may be able to work together.

Name *

Email Address *This will only be used to communicate and share resources with you.

Phone *

Street Address *Your address helps us find the nearest qualified HBOT facility to you.

City *

State *

ZIP / Postal Code *

For which program are you seeking HBOT treatment? *

For which condition(s) are you seeking HBOT treatment? *Traumatic brain injury (including concussion)Post-traumatic stressOther

Do you struggle with any of these ailments?Cognitive issuesLung issuesEar issuesHeadachesSeizuresOther (please describe below)Select any that apply.

Are your ear issues... *Pressure-related (tympanic membrane rupture/blast injury, inability to equalize pressure due to sinus injury)Non-pressure related (tinnitus, chronic infection)I'm not sure

Please provide any helpful details.

Are you a current or former member of the US military? *

Are you currently employed? *

Will you need financial assistance to participate in HBOT? *

Consent *

Yes, I agree that HOW Foundation may use the information I have provided to assess my situation and to contact me for follow-up.

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Please do not fill in this field.

HOW Foundation of South Florida
EIN 46-3568088
1030 Wallace Drive, Suite C
Delray Beach, FL 33444

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