1
Health History
2
Sleep
3
Physical Activities
4
Diagnosis
5
Family History
6
Migraine History
7
Typical Migraine
8
Food & Nutrition
9
Integrative Therapies
10
For women
Health History
Name
Email
Contact No.
Date of birth
Place Birth
Gender
Male
Female
Height
Current weight
One year ago
Occupation
Hours per week
Do you enjoy your current career?
Yes
No
Relationship Status?
Single
Married
Divorced
Separated
Widowed
Children
1
2
3
4
5+
Blood type
A+
AB
B+
A-
O
O+
Pets
1
2
3
4
5+
What is your ancestry?
What are your health goals?
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Sleep
Does your occupation include shift work?
Yes
No
Does your sleep schedule vary?
Yes
No
How many hours of sleep a night?
Do you sleep well?
Yes
Somewhat
No
If not, please describe
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Physical Activities
Do you experience physical exertion headaches?
Yes
Somewhat
No
Does physical activity play a role in your life?
Yes
Somewhat
No
What types of physical activity are you engaged in?
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Diagnosis
Has a physician diagnosed you with migraine headaches?
Yes
No
What diagnosis have you received
What medications have you been prescribed for your migraines?
Medication
Dosage
Reason
What over the counter medications do you take? (Including allergy meds)
Medication
Dosage
Reason
Do you experience any side effects?
Yes
No
Side Effect
Medication
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Family History
Do any other member(s) of your family suffer from headaches/migraines?
Yes
No
If so, who?
What symptoms does he/she normally experience?
How is/was the health of your mother?
How is/was the health of your father?
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Migraine History
How old were you when you had your first headache(s)/migraine(s)?
>10
10-18
1825
26-35
36-50
50+
Do you know what caused or triggered it?
Yes
No
If yes, please describe
How many days per month do you suffer from headaches/migraines?
1-2
3-5
6-12
12-24
24+
Recently have your headaches/migraines been
Same
Better
Worse
Unusual location, type, or pain
How long does your typical headache/migraine last?
1-2 hours
3-5 hours
12-24 hours
24+ hours
2 days to 1 week
What types of migraine(s)/headache(s) do you experience?
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Typical Tigraine
Recently have your headaches/migraines been
Same
Better
Worse
Unusual location, type, or pain
How long does your typical headache/migraine last?
1-2 hours
3-5 hours
6-12 hours
12-24 hours
24+ hours
2 days to 1 week
Other
On a scale of 1-10 how would you rate your typical headache(s)/migraine(s)?
0
1
2
3
4
5
6
7
8
Describe your headache/migraine. Check all that apply.
Aching
Burning
Constant pain
Dullness
Exploding
Pounding
Pressure
Sharp-piercing
Throbbing
Where is your headache/migraine pain located?
Above your eyebrow(s)
Back of your head
Behind your eye(s)
Both sides of head
Entire head region
Front of head
Left side of head
Right side of head
Top of head
Temple(s)
No pattern
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Food Nutrition
What types of foods do you consume on a typical day?
Breakfast
Lunch
Snacks
Dinner
Liquids
Other
Do you cook?
Yes
No
If you do not cook, what is the reason why?
How many times per week do you have home cooked food?
0-3
4-6
7-9
10-12
13-15
15+
Where does the rest of your food come from?
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Integrative Therapies
Do you take any supplement(s) or vitamin(s)?
Yes
No
Supplement
Dosage
Reason
Have you tried any of the following integrative therapies?
Acupuncture
Aromatherapy
Ayurveda
Bodywork
Breathing exercises
Yoga
Chiropractic
Detoxification
Environmental medicine
Fasting
Homeopathy
Meditation
Music therapy
Naturopathy
Neural therapy
Nutritional therapy
Pilates
Prayer
Psychotherapy
Tai chi
Traditional Chinese Medicine
What are three things that you could be doing for your health, but are not?
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For Women
Any pain, stiffness, or swelling?
Yes
No
If yes, please describe
Are your periods regular?
Yes
No
How many days on average is your flow?
How frequent?
What is your birth control history?
Do you experience yeast infections or urinary tract infections?
Yes
No
If yes, please describe
Have you reached or approaching menopause?
Yes
No
If yes, please describe
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