Headache & Migraine Questionnaire

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Medical disclaimer -

This questionnaire is to help us identify what could be causing your headaches. It is for informational purposes only and should not be used as professional advice. If you have a medical emergency you should consult your doctor. If you have had migraines or headaches for less than 3 months, a severe sudden onset of headache or you have a new type of headache over the age of 50 you should consult your doctor immediately.

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Name: *

Phone: *

Please tick the following that have applied to you in the past:

You suffer from neck pain or stiffness either in general, during a headache episode or both

Your headache/migraine can alternate sides during the same episode

Your headache/migraine can alternate sides between episodes

You have had headaches or migraines for more than 3 months

You suffer jaw pain, bruxism or you clench your jaw regularly

You have had a history of physical trauma e.g. motor vehicle accident, concussion, falls

Your headaches are affected by your posture e.g. sitting at a desk, sleeping on your stomach, driving a car etc.

Your headaches can be triggered by certain foods, alcohol or chemicals

Your headaches/migraines are affected by your menstrual cycle

Do you suffer from dizziness or vertigo

You generally feel stressed or anxious

You are a smoker

A copy of your responses will be emailed to the address you provided.

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