• Life With Migraine Educational Coaching

  • Migraine Educational Coaching — New Client Application

  • This form helps me understand where you're starting from. There are no right or wrong answers — just honest ones. Take your time.

  • About You

  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • How did you hear about this coaching program?

  • 01 | Your Migraine History

  • When did you first start experiencing migraine attacks?
  • Have you received a formal migraine diagnosis from a doctor?
  • What type(s) of migraine have you been diagnosed with or suspect you have? (check all that apply)
  • On average, how many migraine days do you have per month?
  • How long do your attacks typically last?
  • What are your most common migraine symptoms? (check all that apply)
  • What are your most common triggers? (check all that apply)

  • 02 | Current Medications & Treatments

  • Are you currently taking any preventive medications for migraine?
  • What acute (rescue) treatments do you use when an attack starts? (check all that apply)
  • Have you tried or are you currently using any of the following non-medication approaches? (check all that apply)

  • 03 | Lifestyle Factors

  • Sleep
  • Do you have any current mental health diagnoses or concerns? (anxiety, depression, PTSD, etc.)
  • How often do you exercise or engage in physical movement?

  • Nutrition

  • How would you describe your typical eating pattern?

  • Caffeine

  • Average daily caffeine intake (coffee, tea, soda, energy drinks):

  • 04 | Your Nervous System Baseline

  • This section helps me understand your baseline nervous system state — a key starting point for the work we'll do together. There are no right or wrong answers.
  • How would you describe how your body feels most of the time? (check all that apply)
  • Do you notice physical signs of stress or overwhelm in your body even when nothing is obviously wrong?
  • If yes, what do you notice? (check all that apply)

  • 05 | Life Stress & Personal History

  • Understanding your broader life context helps me tailor our work together. You're welcome to share only what feels comfortable — you can always add more during our sessions.
  • Are you currently experiencing significant ongoing stress in any of these areas? (check all that apply)
  • How long have you been under elevated stress?
  • Looking back, did your migraine attacks begin or significantly worsen during a particularly stressful or difficult period of your life?
  • Have you experienced significant difficult or painful events in your life (past or present) that you feel may be connected to your physical health or symptoms? You don't need to share details, a simple yes/no is enough here.

  • 06 | Your Relationship With Migraine

  • How we think and feel about migraine has a real effect on the nervous system — this isn't about blame, it's about understanding where you're starting from so we can work with it.
  • When you notice migraine symptoms, what typically happens in your mind? (check all that apply)
  • Do you avoid activities, plans, or situations because of fear of triggering a migraine?

  • 07 | Nervous System Tools You've Tried

  • This helps me understand your starting point so we don't repeat what hasn't worked and build on what has.
  • Have you tried any of the following nervous system or mind-body practices? (check all that apply)

  • 08 | Your Goals for Coaching

  • Thank you for taking the time to fill this out thoughtfully. Your answers will help us hit the ground running
    in our first session. I'm so glad you're here.
    Life With Migraine | lifewithmigraine.com | lifewithmigraine@gmail.com
  •  
  • Should be Empty: