DO YOU HAVE CHRONIC MIGRAINE?


PERSONAL INFORMATION

Name
Date of birth
Email

QUESTIONNAIRE

1.
A. How many days in the past month did you spend with a headache or migraine?
This includes all days with any headache pain, whether you took medication or not.
 
Yes
No
B. Did you enter 15 or more days?
2.
Did any of your headaches/migraines last more than 4 hours if you didn't treat them?
3.
Have you ever been diagnosed as having chronic headaches?
This includes chronic tension-type or chronic sinus headaches.
4.
Have you ever been diagnosed as having migraines?
5.
Do your headaches/migraines impact your daily life?
Rate the impact of your headaches/migraines on your daily life:

  • 1

  • 2

  • 3

  • 4

  • 5

  • 6

  • 7

  • 8

  • 9

  • 10


MILD
SEVERE
How many days in the past month have your headaches/migraines severely affected your daily life?
6.
In the past month, did you take anything to treat your headaches/migraines?
If "yes," how many days in the past month did you take something to treat your
headaches/migraines (including over-the-counter drugs, prescription medication,
and vitamins/herbal remedies)?
Please list what you took:

7.
Is there additional information about your headaches that you would like us to know? Please add your questions or comments here.

Please print this out and bring it to your first appointment. Your answers will help us develop a treatment plan to manage, decrease or eliminate your headache pain.