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40
Questions
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HIPAA
Compliance
1
Is this a new medication or refill request?
New medication
Refill
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2
How long have you had headaches?
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3
Age when headaches began
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4
Onset of a typical attack
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Sudden (peak < 1 min / "thunderclap")
Rapid (minutes)
Gradual (hours)
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5
How long have you had this type of headache?
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New (< 3 months)
Chronic/longstanding
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6
Is this headache
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Same as usual
New or different from past headaches
Worst headache of my life
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7
How many headache days per month?
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8
Average pain level (0–10)
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0
1
2
3
4
5
6
7
8
9
No pain
Worst pain
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9
Where is your headache located?
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10
What does the pain feel like?
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11
Associated symptoms (during headache)
Nausea
Vomiting
Sensitivity to light (photophobia)
Sensitivity to sound (phonophobia)
Sensitivity to smells (osmophobia)
Tearing of the eye
Red/bloodshot eye
Drooping eyelid
Nasal congestion or runny nose (same side as pain)
Neck pain or stiffness
Dizziness / vertigo
Blurred vision
Scalp tenderness
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12
Location / laterality
One side (right / left)
Both sides
Side changes between attacks
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13
Do you typically have nausea, light sensitivity, or aura?
Yes
No
Sometimes
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14
Warning / aura symptoms (before or during headache)
Visual changes (flashing lights, zigzag lines, blind spot)
Numbness or tingling (face, arm, hand)
Difficulty speaking / finding words
Weakness on one side
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15
Aura typically lasts
5–60 minutes
Longer than 60 minutes
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16
Premonitory symptoms hours–days before (fatigue, mood change, neck stiffness, yawning, food cravings)
Yes
No
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17
Pain quality (character)
Pulsating / throbbing
Pressing / tightening
Stabbing / sharp
Dull / aching
Burning
Explosive / sudden
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18
Triggers
Stress
Lack of sleep
Specific foods
Alcohol
Caffeine (or withdrawal)
Menstrual cycle
Weather changes
Bright light
Strong smells
Skipped meals
Exertion
Coughing / straining
Sexual activity
Head position / posture
Other
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19
Have you tried any of these medications
Acetaminophen
Ibuprofen
Naproxen
Aspirin
Acetaminophen–aspirin–caffeine (combination analgesic)
Diclofenac
Ketorolac
Sumatriptan
Rizatriptan
Eletriptan
Zolmitriptan
Sumatriptan–naproxen (combination)
Ubrogepant / Ubrelvy
Rimegepant / Nurtec
Dihydroergotamine
Topiramate
Propranolol
Amitriptyline
OnabotulinumtoxinA
Erenumab (CGRP monoclonal antibody) / Aimovig
Fremanezumab-vfrm / Ajovvy
Nurtec
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20
Current Medications
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21
Allergies:
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22
What helps the most to prevent and stop a headache for you?
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23
Relieving factors
Rest / sleep
Dark, quiet room
Over-the-counter medication
Prescription medication
Caffeine
Cold/hot pack
Nothing helps
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24
Number of headache days per month
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25
Pattern
Episodic (comes and goes)
Daily or near-daily
Clustered in bouts, then pain-free periods
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26
Timing
On waking
Daytime
Evening
Wakes me from sleep
Around menstrual period
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27
Number of completely headache-free days per month
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28
Duration (untreated)
Seconds
Minutes (15–180)
Hours (4–72)
Days
Constant
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29
Usual pain intensity (0–10)
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30
Time from start to peak intensity
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Seconds
Minutes
Hours
Days
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31
Severity
Mild (does not stop activity)
Moderate (limits activity)
Severe (stops activity)
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32
Routine physical activity (walking, climbing stairs, bending) makes the pain
Worse
No change
Better
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33
During an attack I tend to
Lie still / avoid movement
Feel restless / pace / cannot sit still
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34
How many days of school or work have you missed this month?
0-5
6-10
11-15
16-20
21-25
26-31
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35
Red-flag screen (check if present)
Sudden "thunderclap" onset
First or worst headache
Fever / stiff neck
New headache age ≥ 50
Progressive worsening
Weakness, numbness, vision loss, confusion
Head injury
Headache with cough/exertion/position change
History of cancer or weakened immune system
Pregnancy or recent delivery
Unintended weight loss
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36
Basic Information
*
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Full Name
Please enter your email
Please enter your phone
Date of Birth
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37
Home Address
*
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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38
Basic Health Information
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39
Patient Attestation & Acknowledgement
I certify that the information I have provided, including my symptoms, medical history, medications, allergies, and other requested information, is complete and accurate to the best of my knowledge. I confirm that I am physically located in the State of Utah at the time I submit this request for care.I understand that this is an asynchronous telehealth visit, meaning that I will not necessarily communicate with a healthcare provider in real time. A licensed healthcare provider will independently review the information I submit, along with any other available or requested clinical information, before making any diagnosis, treatment recommendation, or prescribing decision.I understand that the provider may request additional information, photographs, medical records, laboratory testing, a telephone or video visit, or an in-person evaluation if needed to safely evaluate or treat my condition. Submission of this questionnaire does not guarantee that treatment or a prescription will be provided.I understand that telehealth has limitations and that certain conditions cannot be safely diagnosed or treated through asynchronous care. If the provider determines that telehealth evaluation is not appropriate for my condition, I may be advised to seek in-person medical care.I certify that I am not currently experiencing a medical emergency. If I develop severe, rapidly worsening, or potentially life-threatening symptoms, I will not wait for a response through this service and will call 911 or seek care at the nearest emergency department.I understand that if my symptoms persist, worsen, change significantly, or do not improve as expected, I should seek additional medical evaluation as directed by my healthcare provider.
YES
NO
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40
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