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Home
Patient Center
Your First Visit
Payment Options
Specialties
Migraine
Remote Migraine Program
Mastering Migraine
Migraine Guide
MQ-7
Concussion
Dizziness/Vertigo
Auto Accident
Low Level Laser Therapy
About us
Meet The Doctors
Dr. Adam Harcourt
Services & Techniques
About Functional Neurology
Testimonials
Contact
Migraine Questionaire
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1. How long have you suffered with migraines?
Within the last month
6 months
About a year
Years, I have been suffering for a long time
2. How severe are your migraines?
Slight (tolerable and causing no limitation)
Moderate (tolerable but causing some limitation)
Severe (causing significant limitations and getting intolerable)
Extreme (causing near constant limitations and definitely intolerable)
3. How do your migraines impact your quality of life?
It doesn’t effect my quality of life much at all
It seems to impact my quality of life, but only from time to time
It has definitely been a significant burden on my quality of life
It has basically robbed me of any quality of life that I used to have
4. What have you already tried to get rid of your migraines?
5. Regarding your location and ability to follow through with treatment.
I do not live in central Pennsylvania and am not able or willing to travel for treatment
I do not live in the central Pennsylvania area but I can force traveling occasionally for treatment
I live within a 1 hour drive and am willing to do what it takes to get treatment
I live close enough that appointments will not be a problem for me
6. Please tell us how you were referred to us or this questionnaire.
7. Type your name
*
8. Email address
9. Phone number
*
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