Name or Alias *

First Name

Last Name

Symptoms

Nausea

Headache

Hernia

Spinal melting

Spiky mucus

Swelling of the jowls

Infra-red sensitivity

Extra or missing digits

Dimensional vertigo

Blistering of the retina

Lacrimal hyper hyperhidrosis

Pupilular dryness

"Stuck neck" syndrome

Sleep screaming (with or without punching)

Verbal or standard diarrhea

Rapid ear movement

Oral foam

Chromatic aberration

Motion blur sickness

Cranial shrinkage

Cranial growth

False memories

Jerabek's syndrome

Color swapping

Eye deflation

Pulsating teeth

Involuntary nipple spasms

Nasal hypercrystalline output

Other (please don't describe)

Did you use the DataVerse™ DataJourney™ Helmet as part of an employment requirement at Conglomerated Enterprises?

No

Yes (this will invalidate compensation options)