Pre Treatment Migraine Headache Questionnaire

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Pre Treatment
Migraine Headache Questionnaire
Date:____________________________
Patient Information
Name:____________________________________ Date of Birth:__________________________
Occupation: _______________________________ Telephone: ______________________________
Male
Female Marital Status:
Married
Single
Divorced
Widowed
Race:
Caucasion
Afr. Amer
Hispanic
Other: ______________________________________
Occupation: ____________________________ Health Insurance:_____________________________
1. How many migraine headaches do you experience per month? ___________________on average
2. How many regular headaches do you have per month? ______________________ on average
3. How long do your migraine headaches usually last after you take your migraine medicine?
No more than 2 hours
3-4 Hours
5-12 hours
12-24 hours
Several days
1 week or longer
How long do your migraine headaches usually last if you do not take your migraine medicine?
No more than 2 hours
3-4 Hours
5-12 Hours
12-24 Hours
Several days
1 week or longer
4. How painful are you migraine headaches? (Circle one number)
5. Where are your migraine headaches usually located? (Check all that apply)
Behind right eye
Behind left eye
Behind both eyes
Right temple
Left temple
Both temples
Above right eyebrow
Above both eyebrows
Back of head on right
Back of head on left
Back of head on both sides
6. How old were you when your migraine headaches started? _________________________________
7. How would you describe you migraine headaches? (Check all that apply)
Throbbing/pounding
Ache/pressure
Like a tight band
Dull
Other:_____________________________________________________________________________
8. Do you migraine headaches awaken you at night?
Never
Occasionally
Often
9. Do any of the following occur before or during your migraine headaches? (Check all that apply)
Nausea
Vomiting
Diarrhea
Speech Difficulty
Runny Nose
Eyelid Puffy
Eyelid Droops
Loss of Vision
Bothered by light/noise
Sparkling, flashing, or colored lights
Feeling lightheaded
Difficulty Concentrating
Numbness/tingling
Blurred/double vision
Weakness of arm or leg
Loss of consciousness
Other: _____________________________________________________________________________

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