Self-care Progress check
Name
*
First Name
Last Name
Today's Date
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Please rate your average headache intensity this week.
Best
1
2
3
4
5
6
7
8
9
Worst
10
1 is Best, 10 is Worst
Please rate your average neck pain level this week.
Best
1
2
3
4
5
6
7
8
9
Worst
10
1 is Best, 10 is Worst
Please rate your average stress level this week.
No stress
1
2
3
4
5
6
7
8
9
Worst stress
10
1 is No stress, 10 is Worst stress
Please rate your average brain fogginess level this week.
Crystal clear
1
2
3
4
5
6
7
8
9
Foggy and heavy
10
1 is Crystal clear, 10 is Foggy and heavy
How many days did you use the headache medication?
Days
0
1
2
3
4
5
6
Days
7
0 is Days, 7 is Days
How many days did you practice headache self-care practice this week?
Days
0
1
2
3
4
5
6
Days
7
0 is Days, 7 is Days
How many days did you attend the virtual group classes this week?
Days
0
1
2
3
4
5
6
Days
7
0 is Days, 7 is Days
How did you hear about us?
Healthcare provider
Instagram
Facebook
Family or Friend
Other
(PGIC) Since beginning treatment at this facility, how would you describe the change (if any) in Activity Limitations, Symptoms, Emotions and overall Quality of Life?
No change (or condition has gotten worse)
Almost the same, hardly any change at all
A little better, but no noticeable change
Somewhat better, but the change has not made any real difference
Moderately better, and a slight but noticeable change
Better and a definite improvement that has made a real and worthwhile difference
A great deal better and a considerable improvement that has made all the difference
Submit
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