Headache Tracker

First Name

Last Name

Email Address

Phone

1. Have you been diagnosed with Chronic Migraine? 1. Have you been diagnosed with Chronic Migraine? Yes No I'm not sure

2. What medication(s) are you currently taking for your headaches and migraine attacks? 2. What medication(s) are you currently taking for your headaches and migraine attacks? Over-the-counter medications such as Excedrin© Prescription medications to treat headaches and migraine attacks once symptoms start Prescription medications to help prevent headaches and migraine attacks before they start None of these Select all that apply.

3. Think back to before you began your current medication(s). How often did you have headaches or migraine attacks? 3. Think back to before you began your current medication(s). How often did you have headaches or migraine attacks? About once a month A few times a month Multiple times a week More days than not (15 or more days a month)

4. In the last month, how many days did your headaches and migraine attacks impact your daily life? For example, did you have to cancel any plans or miss work? 1 to 56 to 1011 to 1516 to 2021 to 2526 to 30

5. Do your headaches or migraine attacks typically last longer than 4 hours? 5. Do your headaches or migraine attacks typically last longer than 4 hours? Yes No

6. When you have a headache, how often do you have any of the following symptoms: nausea or vomiting, sensitivity to light or sound, seeing “spots,” or pain on one side of the head behind the eye or eyeball? 6. When you have a headache, how often do you have any of the following symptoms: nausea or vomiting, sensitivity to light or sound, seeing “spots,” or pain on one side of the head behind the eye or eyeball? Never Less than half the time About half the time Most or all of the time

7. Have you spoken to your doctor about how often you have headaches and migraine attacks and how they affect you? 7. Have you spoken to your doctor about how often you have headaches and migraine attacks and how they affect you? Yes No