Migraine Health Test

First Name *

Last Name

Email *

Primary Phone

Nearest location? *

How did you hear about us? *

MIGRAINE HEALTH QUESTIONS
This test is a self-assessment only and should not be used or construed as medical advice or diagnosis.

Do you notice your migraines caused by a "trigger"? *

Yes

No

Do you suffer from migraines more than 3x per month? *

Yes

No

Do your migraines come from the front/side of your head? *

Yes

No

Do you have an "aura" before or with your migraine? *

Yes

No

Do migraines prevent normal activity 3 days per month? *

Yes

No

Do your migraines last more than 3 hours? *

Yes

No

Do your migraines make you feel nauseated? *

Yes

No

Does light bother you even when not having a migraine? *

Yes

No

From 1 to 10 (10 being the worst), rank your migraine pain *

Comments or Questions?