Pre Treatment Migraine Headache Questionnaire Page 3
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414. Do any of your family members have migraine headaches?
No
Yes If “yes” who:_____________________________________________________
15. Have you ever had a head or neck injury requiring medical treatment (example: concussion)?
No
Yes If “yes” please explain______________________________________________
16. Have you ever been diagnosed to have any health disorder (e.g. high blood pressure, asthma, heart disease,
Gastric ulcer)?
No
Yes If “yes,” please list:_________________________________________________
17. Have you had your migraine headaches evaluated by a neurologist?
No
Yes If “yes”, when, where and by whom?__________________________________
18. List all past tests you have had for your migraine headaches (example: MRI of the brain. CT
brain):__________________________________________________________________________
__________________________________________________________________________.
19. List all past treatment(s) for your migraine headaches:_____________________________________
___________________________________________________________________________.
20. Are you taking any prescription drugs to treat your migraine headaches?
No
Yes If “yes”, please list the medications: _________________________________.
21. How many times in the last month have you used over-the counter medications? :______________
____________________________________________________________________________.
22. Present history of motion sickness:
Yes
No
23. How would you rate your general health in the last month? (Check one)
Excellent
Good
Fair
Poor
24. To what extent do your migraine headaches affect your quality of life? (Check one)
Extremely
Moderately
Very little
Not at all
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