Login Name (Please use your first initial and last name, i.e. jdoe for John Doe
Password *:
Password
again *:
First Name *:(Please use the name you want us to know you by . If your name is "William" but you go by "Bill", please enter "Bill" as your first name)
Last Name *:
E-mail *: Please assure that e-mail address is correct!
City *:
State/Province *:
Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New
Brunswick New
Hampshire New
Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Terr. Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Isl. Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming Yukon
Country *:
United
States Canada Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and
Barbuda Argentina Armenia Aruba Australia Austria Azerbaidjan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia-Herzegovina Botswana Bouvet Island Brazil British
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Verde Cayman
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Republic Chad Chile China Christmas Island Cocos
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Czechoslovakia F ormer
USSR France France (European
Territory) French
Guyana French Southern
Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Gre
nada Guadeloupe
(French) Guam (USA) Guatemala Guinea Guinea Bissau Guyana Haiti Heard and
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(French) Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands
Antilles Neutral
Zone New
Caledonia (French) New
Zealand Nicaragua Niger Nigeria Niue Norfolk
Island North Korea Northern Mariana
Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Island Poland Polynesia (French)Portugal Puerto Rico Qatar Reunion (French) Romania Russian
Federation Rwanda S.
Georgia & S. Sandwich Isls. Saint Helena Saint Kitts
& Nevis Anguilla Saint Lucia Saint Pierre and
Miquelon Saint Vincent
& Grenadines Samoa Sao Tome and
Principe San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovak
Republic Slovenia Solomon Islands Somalia South Africa South Korea Spain Sri
Lanka Sudan Suriname Svalbard and
Jan Mayen Islands Swaziland Sweden Switzerland Syria Tadjikistan Taiwan Tanzania Thailand Togo Tokelau TongaTrinidad and
Tobago Tunisia Turkey Turkmenistan Turks and Caicos
Islands TuvaluUganda Ukraine United Arab
Emirates United
Kingdom United
States Uruguay Uzbekistan Vanuatu Vatican City State Venezuela Vietnam Virgin I slands
(British) Virgin
Islands (USA) Wallis and Futuna
Islands Western
Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe
Gender *:
Male Female
Marital
Status:
Single
Married Divorced Widowed
Occupation:
Your Age at
HFS Onset *:
Side of Face
Affected *:
Left Right Both
Calendar year of HFS
Onset *:
Symptoms
Experienced *:
Medications
Tried: (Include comments on effectiveness
and/or side effects)
Alternative Treatments Tried: (Include comments on effectiveness and/or side effects)
Have you
tried Botox *?
Yes No
If tried,
are you still using it?
Yes
No Not
Applicable
Botox
Comments: (Include comments on effectiveness
and/or side effects)
Have you had
an MVD *?
Yes No
Number of
MVD's:
0 1 2
3 4
Date of last MVD:
January February March April May June July August September October November December , (Month, Day, Year)
Name of last
Doctor who performed your MVD?
Facility
where last MVD was performed? (Name &
address)
If you had
an MVD, are you Spasm Free?
Yes
No Not
Applicable
If Yes to
MVD, any continuing complications?
Miscellaneous Comments: