First Name *:

Last Name *:

Date of Birth *:

Phone Number :

Email :

1. How many types of headache do you have? *

2. How long have your headaches been the way they are now? *

3. How often do you get a headache? *

4. Do you have days without a headache? *

5.How long does your headache typically last? *

6.What do you typically do when you get a headache? *

7.Are you able to continue regular activities or not? *

8.Do you get nauseous or have sensitivity to sound or light when you get a headache? *

9.Are you having a headache right now? *

10.If so, is this as severe as it usually gets ? *

11.Where does your headache usually occurs ? *

12.Is the pain in the same spot or does it changes sides of the head? *

13.Is your headache dull, sharp or throbbing? *

14.Have you developed any other health problems since your headaches began or changed? *

15.Have you noticed a pattern to when your headaches occur or get worse? *

16.What do you take when you get a headache? *

17.Do you take herbal medications or nutritional supplements? *

18.Have you recently changed any of your medications? *

19.Do your headache wake you from sleep? *

20.Do you have a runny nose, drooping eye, or tearing of the eye when you have a headache? *