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First Name:
Last Name:
Email:
Phone:
What is your current rating?
N/A
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Please list down all CURRENT Disability/ies and rating/s for each. (Write N/A if you do not have any current disability rating. Eg PTSD 70%, Sleep Apnea 50%)
Have you ever been diagnosed with the condition you are being prescreened for? If yes, please explain in the box provided below.
Yes
No
What year did your headaches begin?
How old were you at the time?
How many prostrating headaches do you experience each month?
How long do they last?
On a scale of 0-10, on average, how painful are your headaches? (10 being the highest)
0
1
2
3
4
5
6
7
8
9
10
Please briefly describe how these headaches affect your job and family life.
Do you have more than one type of headache?
Yes
No
In your opinion, which of the following triggers your headaches?
Hormonal changes
Stress
Exercise
Relaxation after stress
Change in weather
Bright light / glare
Loud noise
Odors / smoke
Lack of sleep
Too much sleep
Hunger
Alcohol
Certain foods or food additives
Other
Do you get any other symptoms along with your headaches?
Neck pain
Worsening of pain with movement
Nausea / vomiting
Dizziness
Light sensitivity
Numbness
Noise sensitivity
Weakness
Tearing
Confusion
Nasal congestion
Difficulty speaking
Eyelid dropping
Other
What type of actions have you taken to help your headaches?
Rest in a quiet, dark room
Ingest Caffeine
Hot or cold compresses to your head or neck
Take over-the-counter medications
Massage
Other
Are there some days when you are completely free of pain? Describe the pain:
Throbbing
Sharp / stabbing / electric
Pulsating
Pressurized / vise-like compression
Dull aching
Exploding outward
Other
When you have a headache does your scalp and face become sensitive to touch such that you avoid putting on glasses or combing your hair?
Yes
No
What warning signs, if any, do you develop before the start of a headache?
What is the location that best describes where you feel your headaches?
Back
Top
Right Side
Left Side
Front
