Pre treatment Migraine Headache Questionnaire - Bahman Guyuron, MD - Zeeba Clinic

How many migraine headaches do have per month?

How many regular headaches do you have per months?

How long do your migraine headaches last?

How painful are your headaches in the score of 1-10, 10 being most sever headache?

How old were you when your headaches started?

Where does you headache start from?

Left
Behind the eyeAbove the eyebrowBack of the headTemple

Right
Behind the eyeAbove the eyebrowBack of the headTemple

Does headache awaken you at night?
NeverOccasionallyOften

Do you have any of these symptoms before or during headache?

Does any of these bring your migraine or make them worse?

Do any of these make your headache better?

If you are female, Do any of these change your headache?

Menstrual periodsBirth control pillsPregnancyHormonal medication

Do you have any family members with migraine headaches?
YesNo

If yes, who?

Did you ever had neck injury, requiring treatment?
YesNo

If yes, please explain:

Who is your neurologist?
Don't have one

Name and contact information?

Please list all of your diagnostic tests for migraine headache

Please list all of your medications for migraine and other conditions:

How many day of work/school do you loose in a month?

To what extent migraine headache affects your life?
NoneVery littleModerateExtremely