Migraine Questionaire

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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