Neurogenics Migraine Wellness Clinic

Migraine Profile

First Name *

Last Name *

Date of birth *

Email *

Main Occupation *

Have you been formally diagnosed with migraine? *

yes

not sure

Neurogenics Migraine Profile

Section 2

Frequency, Severity and Duration

Do you take medication or treatments during your migraine attacks? *

yes

Neurogenics Migraine Profile

Section 3

Prodrome ( Early Warning Signs )

Before your migraine begins, do you notice any of the following? (Tick all that apply) *

How long before the headache do these symptoms appear? *

Minutes

Hours

A day or more

Neurogenics Migraine Profile

Section 4

Aura ( if applicable )

Do you experience an aura before the headache phase? *

yes

If yes, which types of aura do you experience? (Tick all that apply) *

How long do the aura symptoms last? *

< 5 minutes

5–20 minutes

20–60 minutes

Over 60 minutes

Neurogenics Migraine Clinic

Section 5

Headache Phase

Where is the pain usually located ? ( tick all that apply ) *

One side of head

Both sides

Behind the eye(s)

Neck or base of skull

Which of the following accompany the headache? (Tick all that apply) *

Neurogenics Migraine Profile

Section 6

Post Drome

Do you experience any of the following after the migraine? (Tick all that apply) *

How long does the postdrome phase usually last? *

< 4 hours

4–12 hours

12–24 hours

Over 24 hours

Neurogenics Migraine Profile

Section 7

Patterns & Triggers

What do you think triggers your migraines? (Tick all that apply) *

Neurogenics Migraine Profile

Section 8

Personal Notes

In your own words, describe how migraines affect your quality of life: *