Medical Questionnaire Form

For how many years you have Migraine Headaches?

Medications

How often did you need to see a doctor for migraine

per weeks

months

quarter

Any Surgical Treatment

Yes

No

If yes explain

Have you experienced aBotulinum Toxin Trx: how many units and how often ?

Results

Improved/resolved

Not improved

Worsen

Migraine Headaches

LT. side

Rt.Side

Both Side

Neck Pain/Stiffness

Dose the Migraine radiates to behind your eye(s)

Yes

No

Do you lose vision?

Yes

No

If yes explain

How often attacked by Migraine

Daily

Weekly

Monthly

Quality of Pain

Sharp

Dull

Shooting

Burning

Severity of pain

none

mild

moderate

severe

Name all medications you took for migraine relief:use additional page if needed, please

Are you able to provide all the Tests and studies done for you in the past( such as Ct-Scan, MRI, Nerve conduction etc.)?

Yes

No

Are you willing to provide a written or recorded testimonial for electronic Media?

Yes

No

If Yes Please sign below

Temples	Behind the eyes	Back of the head	Nasalcongestion
Tongue symptoms	Lightening	Smelling

Nausea/Vomiting	Numbness/Tingling	Speech loss
Visual disturbances	Seizure activity

Cold weather, Drink	Music/ Wind	Certain Smells
Electronic games/TV/PC-monitor	Certain Food	Others