Migraine Headache Daily Log

1. Default Section

Please fill out this log on a daily basis. Remember to enter your name, email address, and unique Personal Identifier Number (PIN)

Question Title

* 1. Personal Information

Name (optional)

Email Address

Create a unique ID (4-8 characters)

Question Title

* 2. Please enter today's date.

MM/DD/YYYY

Question Title

* 3. Did you have a migraine headache today?

Yes

Question Title

* 4. List the time it began and ended.

Begin

End

Question Title

* 5. What is the total time in a 24 hr period that you dealt with a migraine related issue?

Question Title

* 6. Rate the intensity of the migraine. (1=mild, 10=severe)

	1	2	3	4	5	6	7	8	9	10	N/A
Severity	Severity 1	Severity 2	Severity 3	Severity 4	Severity 5	Severity 6	Severity 7	Severity 8	Severity 9	Severity 10	Severity N/A

Question Title

* 7. Location of Migraine

	Behind/around Eye	Above Eyebrows	Temporal Region	Back of Head/neck region
Right	Right Behind/around Eye	Right Above Eyebrows	Right Temporal Region	Right Back of Head/neck region
Left	Left Behind/around Eye	Left Above Eyebrows	Left Temporal Region	Left Back of Head/neck region

Other (please specify)

Question Title

* 8. Please enter all medications taken today to treat your migraine and the dosage.

Question Title

* 9. Check all that apply which were associated with your migraine.

Nausea

Vomitting

Diarrhea

Sensitivity to light/noise

Blurred or double vision

Sparkling lights

Eyelid droops

Puffy eyes

Loss of vision

Lightheadedness

Numbness/tingling

Weakness of arms/legs

Difficulty concentrating

Speech difficulty

Loss of consciousness

Runny nose

Aura

Beginning of menstrual cycle

Other (please specify)

Question Title

* 10. Did any of the following trigger your migraine? (check all that apply)

Stress

Bright light/sunshine

Weather Change

Let down after stress

Loud Noise

Heavy Lifting

Air travel

Fatique

Smells of perfume

Missed Meals

Sexual Activity

Straining/bending

Food

Other (please specify)

Question Title

* 1. Personal Information

Question Title

* 2. Please enter today's date.

Question Title

* 3. Did you have a migraine headache today?

Question Title

* 4. List the time it began and ended.

Question Title

* 5. What is the total time in a 24 hr period that you dealt with a migraine related issue?

Question Title

* 6. Rate the intensity of the migraine. (1=mild, 10=severe)

Question Title

* 7. Location of Migraine

Question Title

* 8. Please enter all medications taken today to treat your migraine and the dosage.

Question Title

* 9. Check all that apply which were associated with your migraine.

Question Title

* 10. Did any of the following trigger your migraine? (check all that apply)

Question Title

* 11. Please enter any other events associated with your migraine today.