Migraine Assessment

How long have you been experiencing migraine and/or headaches?

Under 6 Months 6 Months - 2 Years 2 - 5 Years 5 Years or more

At what age did your migraine and/or headaches start?

Before 9 years old 10 - 15 years old 16 - 30 years old 31 - 45 years old 46 years or older

How often do you experience migraines and/or headaches?

Less than once a month 1 - 2 times a month 3 - 4 times a month 5 - 12 times a month Daily

How long do your worst migraine attacks and/or headaches last?

Under 1 hour 1 - 4 hours 4 - 24 hours 24 hours or more

How much do migraine attacks and/or headaches interfere with your daily activities?

Not at all A little A moderate amount A lot A great deal

Do you ever experience any of the following before the pain of your migraine and/or headache begins?

Irritability

Depression

Muddled Thought

Fatigue

Yawning

Increased Urination

Muscle Stiffness

Visual Disturbances

Numbness

Tingling

Ringing in Ears

Yes No

Anything specific you'd like us to know about what you experience before or after your migraine attack?

Does caffeine or triptan medication relieve your migraine and/or headaches?

Yes No

Do your migraine attacks and/or headaches ever last more than 4 hours?

Yes No

Do your migraine attacks and/or headaches throb?

Yes No

Do you experience any of the following during or after your migraine and/or headache?

Pain, nausea, vomiting, neck pain, anxiety, sensitivity to light, sound or smell, insomnia, confusion, fatigue, lack of concentration, depressed mood, or euphoria.

Yes No

Have you tried prescription medication for longer than three months?

Yes No

If you're interested in speaking with a migraine specialist, we'd love to hear from you! Please call our office at (801) 658-4564. Push "Finish" to return to the home page.

Call anytime 8am to 7pm, Monday - Friday.

Based on your answers, your situation sounds very severe. We think you'd be a good candidate for our migraine treatment program. To schedule a telehealth consultation with our doctor, enter your information below and we'll contact you to schedule a time.

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Migraine Assessment

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