THANK YOU AND WELCOME TO FOCUS CHIROPRACTIC!
This is a quick 10-item screening questionnaire designed to recognise migraines and tension type headaches. Simply enter your name and email address, answer the below questions and hit the submit box.
Name
First Name
Last Name
Contact number
Email
example@example.com
1. How often in your life have you had a headache?
1 - 4 episodes
5 - 9 episodes
10 episodes or more
2. Looking back at the last question, how often would you describe those headache moments as a headache-attack?
1 - 4 episodes
5 - 9 episodes
10 episodes or more
3. How many days per month do you have headaches?
Less than 1 per month
1 - 15 per month
More than 15 per month
4. How long does your headache last when you do not take any medication?
0 - 30 minutes
30 minutes - 4 hours
4 hours - 3 days
3 days - 7 days
More than 7 days
5. What word would you use to describe your headache?
Pulsating feeling
Tight or pressing feeling
Burning or stabbing feeling
Other, such as
6. Is your headache one-sided or two-sided in nature?
One-sided
Two-sided
7. Describe the severity of your headache
Mild
Moderate
Severe
Very severe
8. Daily activities such as climbing stairs or walking make my headache worse.
Yes
No
9 I avoid daily activities when I have a headache.
Yes
No
10 Describe what you experience during your headache (multiple answers possible).
Sensitivity to light
Sensitivity to sound
Nausea and/or vomiting
None of the above
All information will be kept strictly confidential. Thank you for participating in this questionnaire.
Submit
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