1. Default Section

Migraine Relief Centers is a group of physicians dedicated to improving the quality of life of patients suffering from migraine headaches. This survey will take approximately ten minutes to complete.

* 1. How many migraine headaches do you experience per month.

* 2. Age you first experienced a migraine?

* 3. What is your gender?

* 4. How many regular headaches do you experience in a month?

* 5. How long do your migraine headaches last if you do not take medications?

* 6. How long do your migraine symptoms last after you have taken medications to help it?

* 7. Rate the severity of your migraine head-aches on a scale of 1-10. (1=mild and 10=severe)

  1 2 3 4 5 6 7 8 9 10
1

* 8. How would you describe your head-ache? (check all that apply)

* 9. Where the majority of your migraines occur. (check all that apply).

* 10. Based on the location of the major migraine, what is the frequency of episodes/week. (check all that apply).

  Behind Right Eye Behind Left Eye Above right eye Above left eye Right Temple Left Temple Back of head (right side) Back of head (left side)
0-1
2-5
5-10
>10

* 11. Rate the severity of the migraine in relationship to the location of the migraine on a scale from 1-10 (1=mild and 10=worst.)

  1 2 3 4 5 6 7 8 9 10
Behind Right Eye
Behind Left Eye
Above right eye
Above left eye
Right Temple
Left Temple
Back of head (right side)
Back of head (left side)

* 12. Rate the duration in hours each migraine lasts specific to the location you experience the migraine.

  1-2 hours 6 hours 12 hours 24 hours > 24 hours
Behind Right Eye
Behind Left Eye
Above right eye
Above left eye
Right Temple
Left Temple
Back of head (right side)
Back of head (left side)

* 13. Do your migraine head-aches awake you from sleep?

* 14. Are any of the following symptoms associated with your head-aches? (check all that apply)

* 15. Do any of the following bring on your migraine headaches or make them worse? (Check all that apply)

* 16. Do any of the following make your migraine headaches better?

* 17. If you are female, do your migraine headaches change with the following? (Check all that apply)

* 18. Do any of your family members have migraine headaches?

* 19. Have you ever had a head or a neck injury requiring medical treatment?

* 20. Have you had your migraine headaches evaluated by a neurologist? If yes, whom?

* 21. What type of treatment/treatments have you had in past? (check all that apply)

* 22. Have you had any of the following tests/treatments for migraines? (check all that apply)

* 23. Are you taking any over-the-counter drugs to treat your migraine headaches? (check all that apply)

* 24. Are you currently taking any prescription drugs to treat your migraine headaches? If so, which ones?

* 25. What is your estimated cost per month of your migraine headache medications and visits to the physician?

* 26. How would you rate your general health in the last month? (Check one)



* 27. In the last month, how days have you missed from work as a direct result a migraine attack?

* 28. In the last year, how days have you missed from work as a direct result a migraine attack?

* 29. To what extent do your migraine headaches affect your quality of life? (Check one)



* 30. Have you ever heard of treatment of migraines with Botox?

* 31. If there was a surgical procedure to help improve and control your migraine head aches, would you be willing to undergo an outpatient procedure?

* 32. If you are interested in learning more on the new advances in the treatment of migraine headaches please provide your email address below and a migraine consultant will respond to you.

* 33. Would you like a migraine consultant to review your responses to see if you are a candidate for chemical or surgical treatments of migraine? (if yes, you must provide a way to contact you)

* 34. If you would like us to provide you with more information, please fill out the demographics portion of this survey. All answers are optional.

Thank you for taking this survey. Your answers are strictly confidential and will not be shared with anyone other than the staff and physicians of the Serenity Migraine Center.

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