Trigeminal Dysphoria Questionnaire
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are you currently experiencing any of the following?
*
Rows
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
Headaches
Problems Focusing
Double Vision
Eye Pain/Strain
Words Move on Page
Motion/Car Sickness
Movement Sensitivity
Light Sensitivity
Nausea
Clumsiness
Attention Problems
Neck Pain/Whiplash
Disorientation
Dizziness
Memory Problems
Anxiety/Worry
Depression/Despair
Anger/Irritability
Overwhelm/Emotional
Excitement/Joy
Would you like our office to contact you to schedule an appointment?
*
Yes
No
Submit
Should be Empty: