Migraine Study
Please answer the below questions and then continue to the calendar to schedule an appointment with us!
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Age
*
1. Kindly document the following information:
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2. In an average month, how many migraine days do you have?
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3. How many hours does an average migraine episode last?
4. Which of the following medications if any have you tried for your migraines?
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Acetaminophen
Sumatriptan (Imitrex)
Rizatriptan (Maxalt)
Zolmitriptan (Zomig)
Botox
Gabapentin (Neuronton)
Depakote
Emgality
Aimovig
Nurtec
Topamax
Antidepressants
Beta blockers ( such as atenolol, bisoprolol, metoprolol, nadolol,
propranolol, timolol)
Verapamil
Candesartan (Atacand)
Lisinopril (Zestril)
Methysergide (Deseril)
Other
Any other medications. Kindly provide the names below -
5.Have you ever had a cholecystectomy or been diagnosed with gallstones?
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Yes
No
6. Have you ever been diagnosed with ulcerative colitis or chronic pancreatitis?
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Yes
No
7. Have you ever had any weight loss surgery?
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Yes
No
8. Have you been diagnosed with cancer in the last 5 years?
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Yes
No
20180 W. 12 Mile Road, Southfield, MI 48076
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