| Patient Name:* |
|
| Date of birth: * |
/
/
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| Primary Phone #: * |
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| Secondary Phone #: |
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| Email Address: * |
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Have you been diagnosed
with migraine headaches? * |
Yes
No |
| |
When were you diagnosed
with migraine headaches? |
Less than 1 year
1 year or longer |
| |
Are you currently being treated
for migraine headaches? |
Yes
No |
| |
On average, how many days
a week do you have headaches? |
1 - 2 days
3 - 4 days
4 - 5 days
More than 5 days |
| |
Has your physician ever prescribed
a pill that you take every day to
prevent migraine headaches? |
Yes
No |
| |
Are you currently taking any of the
following medications on a daily
basis for any reason?
(Check all that apply) |
Topamax (Topiramate)
Depakote (Divalproex Sodium)
Neurontin (Gabapentin)
Inderal (Propranolol)
Toprol (Metoprolol Succinate)
Lopressor (Metoprolol Tartrate)
Corgard (Nadolol)
Elavil (Amitriptyline)
Pamelor (Nortriptyline)
Prozac (Fluoxetine)
Effexor (Venlafaxine)
Calan (Verapamil)
Lyrica (Pregabalin)
Tenormin (Atenolol)
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| Comments: |
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What medication have you taken
for your migraine?
(CHECK ALL THAT APPLY) |
Aleve
Amerge
Axert
Excedrin
Frova
Ibuprofen
Imitrex
Maxalt
Naproxen Sodium
Prozac (Fluoxetine)
Relpax
Treximet
Tylenol
Zomig
|
List in comment box any other
headache/ migraine medications
you routinely take. |
|
| |
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