Name Surname: E-mail Address: Date: City: Gender: FemaleMale Date of Birth: Phone Number: Your Marital Status: The marriedSingle Educational Status: Job: 1.How old were you when you first had a migraine attack? EverydayOnce a weekTwice a weekOnce a month 2.Do you know what caused or triggered it then? EverydayOnce a weekTwice a weekOnce a month 3.Do other members of your family suffer from migraines? 2 hours and less3 or 4 hours5 or 12 hours12-24 Hoursin a few days1 week or longer in duration 4.How many days a month do you have "normal" headaches? 2 hours and less3 or 4 hours5 or 12 hours12-24 Hoursin a few days1 week or longer in duration 5.How many days a month do you suffer from migraines? 12345678910 6.How long does your migraine last on average? Right behind the eye Left behind the eye Both behind the eye In the right temple In the left temple Both in the temple on the right eyebrow on the left eyebrow On both eyebrows Right in the neck area Left in the neck area On both sides of the neck 7.How painful are your migraine attacks? 8.Where do you experience the majority of your migraine-related pain? Throbbing / Percussion Pain / Print like a band compressed Staggering Order Throbbing / Percussion Pain / Print like a band compressed Staggering Order 9.During a migraine attack, do you usually experience pressure or pain in the nose? NeverSometimesOften 10.Is your migraine related to changes in the weather? (Please tick all that apply.): Nausea vomiting see sparkle Light / Noise Disturbance Condensation / Double Vision Vision Loss Eyelid swelling Eyelid sagging Arm / Leg fatigue Dizziness Numbness Loss of consciousness Difficulty of Concentration Speech Difficulty Nasal Discharge Diarrhea 11.Do you wake up at night due to migraine pain? Stress (anger / worry) Sunlight Weight lifting Frustration High Noise Odor / Fragrance Aircraft Travel Fatigue Coughing / sneezing Meal Abduction Sexual Activity Specific Food / Beverages Weather change 12.Have you ever suffered one or more of the following symptoms before or during a migraine attack? Rest Exercise Hot Applications Massage Cold Applications Silence / Dark Migraine Regional Printing Warm Shower 13.Do you suffer from increased sensitivity to pain before or during a migraine attack? Number Periods Birth Control Pills Other Hormonal Drugs Pregnancy 14.What gives you relief during a migraine attack? 15.What triggers or exacerbates (worsens) your migraine ? 16.If you are a women, is/was your migraine affected by the following? If so, in what way? 17.Have you ever had one of the following medical problems? 18.Have you ever been examined and treated by a doctor for your migraines? 19.Have you had any of the following tests for your migraine? 20.Do you take medications for your migraines? 21.Do these treatments help you? 22.How many times did you see a doctor last year about your migraines? 23.How many different doctors did you see last year about your migraines? 24.Do you do anything to prevent a migraine attack from occurring? Very GodGodNormalBad 25.How many days were you absent from work last year due to migraines? Too MachNormalLittleAny
