Fillable Migraine Questionnaire Template printable pdf download

Migraine Questionnaire Template

Download a blank fillable Migraine Questionnaire Template in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Migraine Questionnaire Template with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

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Kevin G. Rose M.D.

Migraine Questionnaire

Name:_____________________________________

Date:______________________

Home Phone #:______________________________

Work Phone #:______________

 Female

 Male

Date of Birth:________________________________

Married

Single

Divorced

Widowed

Marital Status:

Caucasian

Afr. American Hispanic

Other

Race:

Education Level: HS Grad

2yr degree

4yr degree

Adv. Degree

Occupation:__________________________________Health Insurance Co.:_____________________

1: How many migraines do you have per month?:__________________________________________

2: How many regular headaches do you have per month?:__________________________________

3: How long do your migraine headaches last?: (check One)

No more than two hours

3-4 Hours

5-24 Hours

Several Days

1 week or longer

4: How painful are your migraine headaches (circle one)

---1---/---2---/---3---/---4---/---5---/---6---/---7---/---8---/---9---/---10---/---

Mild

Severe

5: Where are your migraine headaches located (check all that apply)

Behind right eye

Behind left eye

Behind both eyes

Right temple

Left temple

Both temples

Above right eyebrow

Above left eyebrow

Above both eyebrows

Back of head right side

Back of head left side

Back of head on both sides

6: How old were you when your migraine headaches started?:_______________________________

7: How would you describe your migraine headaches (check all that apply)

Throbbing/pounding

Ache/pressure

Like a tight band

Other___________

8: Do your 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

Bothered by light/noise

Blurred/double vision

Sparkling, flashing, lights

Eyelid puffy

Eyelid droops

Loss of vision

Feeling light headed

Numbness/tingling

Weakness of arm or leg

Difficulty concentrating

Speech difficulty

Loss of consciousness

Runny nose

Other_______________________________________________

10: Do any of the following bring on your migraine headaches or make them worse? (check all that apply)

Board Certified by the American Board of Plastic Surgery

Migraine Questionnaire Template

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