Headache Survey

Take this brief survey to find out which procedures you may be a good candidate for.
* Identifies required questions.

1. Name *

2. Age

3. Sex *

4. E-mail *

5. Do you have a treating neurologist/headache specialist? *

If yes, what is their name and city/state of their practice?

6. Do you currently have an established headache diagnosis? If yes, what is it?


other:

7. How many years have you been suffering from headaches? *

8. Average number of headache days per month *

9. Average severity (1 being minimal discomfort / 10 being the worst pain you can imagine) *

10. Have you ever had Botox injections for your headaches? *

If yes - did it work?

11. Have you ever had nerve block injections for your headaches? *

If yes - did it work?

12. When do your headaches usually start? (select one)

13. Which side of your head are your headaches located? *

14. Where are your headaches usually located? (select all that apply)

15. What areas are tender before, during, or after a headache? (select all that apply)

16. Does pressure or massage on the following areas reduce or eliminate the headache pain? (check all that apply)

17. Does your headache get worse or start because of a change in the weather or a change in altitude (flying in an airplane)? *

18. Do you have any of the following associated with your headache? (select all that apply)

19. Have you ever had a neck injury or whiplash? *

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