Where are you experiencing your headache?
Starting in my neck, going to the back of my head
Back of my head
Sides of my head
In front, behind my eyes or forehead
Rate the severity of your pain, on a scale from 1-10.
1-3
4-6
7-8
9-10
How often are you experiencing headaches?
Constant
Several times a week
Several times a month
A few times per year
When do you most often experience headaches?
At night
In the morning
After a long day at work
Do you get headaches due to any of the following?
Lack of Caffeine
Not enough Water
Chocolate
None of the above
Does any of the following help your headache?
Lying in a dark room
Applying ice to my head or neck
Over the counter medications (i.e. Ibuprofen)
Nothing helps my headache
Have you seen a chiropractor before for this pain?
Yes
No
How was the experience?
Great, it really helped!
Good, but the pain persisted.
Not good.
Great! Now let us know where to send your results.
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