Headache Survey Questionnaire Form

HEADACHE/MIGRAINE EVALUATION

Headache Relief 905-953-1028
Name

First NameLast Name
Best E-mail
Best Phone Number

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

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

minuteshoursdaysweeks
My headaches feel:

throbbing/pulsatingtight/pressing"band-like"that they start in my neckOther
My headaches:

are one-sidedare on both sidesaffect whole headcause facial paincauses visual symptoms or nauseais made worse with light or soundseem to come from my neckseems be be affected by movement of my head or neckseems to be worse with activityOther
My headaches seem to be triggered by:

weather changedairy productscaffeinered winestressdehydrationfatigueOther
My headaches disrupt:

worksleepfamily timehobbiessportseverythingOther
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