First Name *

Last Name *

Age *

E-Mail *

City/State *

When do they occur? *

What triggers them? *

What relieves them? *

What other symptoms occur with the headache? *

How long have you been experiencing them for? *

Have they changed recently? If so, how. *

On average, how many headaches do you have each month? *

How long does each headache normally last for? *

How many headaches each month are associated with other symptoms such as nausea, changes in vision, sensitivity to light or sound; or an inability to conduct your normal daily activities? ( Choose all that apply) *FeverNeck StiffnessSevere VomitingDizziness or UnconsciousnessWeakness or tingling in any part of your bodyChanges in your visionA recent head injuryWaking you from sleep

What investigations have you had for your headaches? (Choose all that apply) *XRayMRICT ScanBlood TestNone

Have you seen a specialist for this before? If yes, who? *

If any, what treatments have you previously had for headaches? *

Are you currently on any blood thinning medications? (e.g. Warfarin) *YesNoUnsure

What treatments are you currently on for your headaches? *

Have you previously been diagnosed with any sort of cancer or immune related disease *YesNo

Is there any chance you may be pregnant *YesNo