Headache Survey Questionnaire Form

HEADACHE/MIGRAINE EVALUATION

Headache Relief 905-953-1028
Name

First Name Last Name
Best E-mail
Best Phone Number

Area Code Phone Number
How long have you or your loved one suffered from headaches?

less than a year greater than a year
How often do the headaches occur?
My headaches last:

minutes hours days weeks
My headaches feel:

throbbing/pulsating tight/pressing "band-like" that they start in my neck
My headaches:

are one-sided are on both sides affect whole head cause facial pain causes visual symptoms or nausea is made worse with light or sound seem to come from my neck seems be be affected by movement of my head or neck seems to be worse with activity
My headaches seem to be triggered by:

weather change dairy products caffeine red wine stress dehydration fatigue
My headaches disrupt:

work sleep family time hobbies sports everything
How important is it for you to get better? (on a scale of 1-10, 10 being extremely important):
We will be in touch with you shortly. If you have any questions in the meantime, please call us at: (905) 953-1028
Chiropractic on Eagle, Dr. Jon Saunders

407 Eagle Street, Newmarket, ON L3Y1K5

905.953.1028 www.chirofirst.ca
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HEADACHE/MIGRAINE EVALUATION