Initial Consultation_Version2 - Daith Piercing 2020

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1. Please Fill In Your Details Below

First Name

Surname

Address

Address 2

City/Town

State/Province

Postal Code

Phone Number

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2. Email address

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3. Today's Date

Date / Time

Date

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4. What clinic is this today

Sussex - Burgess Hill

London - Harley Street

Home Visit

Other

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5. Are you Male or Female

Male

Female

Trans Gender

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6. Your age Please

15/20

20/30

30/40

40/50

50/60

60/70

Over 70

Other (please specify)

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7. What do you do for a living / during the day

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8. What best describes your symptoms - tick appropriate

Bilateral Migraine

Left Migraine

Right Migraine

Tension Headache

Cluster Headache

Head Fog

Constant Head Fog

Anxiety

Hyper Vigilance

Post Traumatic Stress Disorder PTSD

Obsessive-Compulsive Disorder OCD

Depression

Silent Migraine

Stomach Migraine

Irritable Bowel Syndrome IBS

Fibromyalgia only

Tremors

Neck Tension

Shoulder Tension

Vertigo

Nightmares

Flashbacks

Other (please specify)

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9. How was the initial stimulation test

Very Positive on Left & Right

Somewhat Positive on Left & Right

Not positive on Left & Right

Left only - Very Positive

Left only - Somewhat Positive

Right only - Very Positive

Right only - Somewhat Positive

No Reaction

Negative Left

Negative Right

Other (please specify)

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10. Is this consultation Migraine / Headache related

Yes

Initial Consultation_Version2 - Daith Piercing 2020

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* 1. Please Fill In Your Details Below

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* 2. Email address

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* 3. Today's Date

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* 4. What clinic is this today

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* 5. Are you Male or Female

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* 6. Your age Please

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* 7. What do you do for a living / during the day

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* 8. What best describes your symptoms - tick appropriate

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* 9. How was the initial stimulation test

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* 10. Is this consultation Migraine / Headache related

1. Please Fill In Your Details Below

2. Email address

3. Today's Date

4. What clinic is this today

5. Are you Male or Female

6. Your age Please

7. What do you do for a living / during the day

8. What best describes your symptoms - tick appropriate

9. How was the initial stimulation test

10. Is this consultation Migraine / Headache related