Headache Questionnaire

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QRS

Queensland Rehabilitation Specialists Migraine Clinic
Location: 48 Annerley Road, Woolloongabba QLD 4170

Please complete the migraine and headache questionnaire below with necessary details. We can contact you with more information regarding migraine clinics and treatment options.

* Indicates required field

Name *

First

Last

Date of Birth *

Postal Address *

Email *

Describe your usual pattern of headaches

When do they occur? *

What triggers them? *

What relieves them? *

What other symptoms occur with the headache? *

How long have you been experiencing them for? *

Have they changed recently? If so, how. *

On average, how many headaches do you have each month? *

How long does each headache normally last for? *

How many headaches each month are associated with other symptoms such as nausea, changes in vision, sensitivity to light or sound; or an inability to conduct your normal daily activities? *

Are your headaches associated with: (Choose any which apply) *

Fever Neck Stiffness Severe Vomiting Dizziness or Unconsciousness Weakness or tingling in any part of your body Changes in your vision A recent head injury Waking you from sleep

What investigations have you had for your headaches? Choose all that apply *

XRay MRI CT Scan Blood Test None

Have you seen a specialist for this before? If yes, who? *

If any, what treatments have you previously had for headaches? *

Are you currently on any blood thinning medications? (e.g. Warfarin) *

Yes No Unsure

What treatments are you currently on for your headaches? *

Have you previously been diagnosed with any sort of cancer or immune related disease? *

Yes No

Is there any chance you may be pregnant? *

Yes No

Submit

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