Exit this survey 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 Date Question Title * 3. Did you have a migraine headache today? Yes No Question Title * 4. List the time it began and ended. Begin Time AM/PM - AM PM End Time AM/PM - AM PM 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. 1. 2. 3. 4. 5. 6. 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 * 11. Please enter any other events associated with your migraine today. Done