Williamsville
Orchard Park
| Fax: (716) 626-9193
(716) 626‑0093
Billing: (716) 281-0055
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PATIENT PORTAL
Migraine Questionnaire
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Migraine Questionnaire
Chronic Migraine Questionnaire
"
*
" indicates required fields
A. How many days in the past month did you spend with headache/migraine? (Include ALL days with any headache pain of any kind, even those you didn't feel you needed to take any medication for or only took an over-the-counter medication).
*
B. How many days in the past month did you spend without ANY headache pain of any kind (headache-free days)?
*
C. Days with headache (31 minus days with no headache)
1. Do the days in either A or C equal 15 or more?
Yes
No
2. Did any of your headaches/migraines last more than 4 hours if you didn't treat them?
Yes
No
3. Have you ever been diagnosed as having chronic headaches (including chronic tension-type or chronic sinus headaches)?
Yes
No
4. Have you ever been diagnosed as having migraines?
Yes
No
5. Do your headaches/migraines impact your daily life?
Yes
No
Rate impact on your daily life, from 1 (Mild) through 10 (Severe):
1
2
3
4
5
6
7
8
9
10
How many days in the past month have your headaches/migraines severely affected your daily life?
6. In the past month, did you take anything to treat you headaches/migraines?
Yes
No
If "yes," how many days in the past month did you take something to treat your headaches/migraines (including over-the-counter drugs, prescription medication, and vitamins/herbal remedies)?
Please list what you took:
Check below if the following applies
Check here if you answered "YES" to both 1 and 2 and at least one of the other questions. You may have chronic migraine.
LAST NAME
*
FIRST NAME
EMAIL ADDRESS
*
PHONE NUMBER
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