Migraine, Tension Headache, Cluster, & TN Medical
Data Form : 


Jane Doe

Country and City


Which of the following triggers your pain:


How often do the attacks typically occur?

Less than once a month

Where in your head face and neck do you experience the pain?

Left Temple
Back of the head/neck

Indicate the pain levels of the worst attacks on a scale of 1 to 10 where 1 is very mild and 10 is the worst pain imaginable.


Which of the following are applicable to you?

Pain mostly/only on the right side of the head
Pain on both left and right sides of the head

Do you experience any of the following?

Phono-phobia (sensitivity to sound)

Symptoms during attack

Tearing eye

Red eye

Do you experience any visual disturbances before or during an attack?

Blurred vision

Double vision

Are any of the visual disturbances PERMANENT and NEVER seem to go away?


Do you experience any of the following:

Pain or discomfort when your head touches your pillow

Are you Experiencing any of the following?

Vertigo, dizziness

Select any of the following if applicable:

None of the above

When did the headaches, migraines or cluster attacks first start? At what Age?

7 years old

How old are you now? (This simple information is critical for us to make decisions about which members of our team you may need.)

28 years old

Have you consulted with any of the following types of doctors or specialists for your headaches/migraines? (We do not want to repeat anything and we may need information from these specialists)

Ear, Nose and Throat Specialist
General Practitioner

Have you undergone any of the following tests or procedures for your migraines / headaches?

CT scan

Are there any other tests or procedures you have undergone, or other specialists you have seen that are not listed above?


How long do the attacks typically last?

5 days

How many days in the month are you 100% pain free?

15 days

Movement of the pain.

The pain is only right side and the neck

Is there any trauma that you recall that could be linked to the onset of your headaches?


Did your headaches manifest subsequent to having a surgical procedure?


Has the pain changed over time?


Do you grind your teeth?


When you bite or clench your teeth, are the any painful points or notable pressure points?


Have you had any of your wisdom teeth removed?


Do you have any difficulty or discomfort opening your mouth?


Do you have dentures?


Do you experience any jaw clicking?


Do you experience any pain or stiffness in the jaw while eating/chewing?


Please list any medications you are currently taking. Click the “+” sign to enter another line:
Name of medication       Dosage           Number of times per day      Related condition

Amytriptiline                             10 mg                                    1                                              Migraine

Migraine kit                             Whole kit              When I have migraine                            Migraine

mybulen                                   2 tablets               When I have migraine                            Migraine

We aim to reduce medication intake by reducing pain but for diagnostic purposes we need to know if you have you tried any of the following medications?

Magnesium tablets

Have you experienced any of the following:

Downward spiral into constant pain and medication dependence

Do you use oral contraceptives?


Is your pain correlated with hormonal cycles?

Not sure

Are headaches worse with any of the following:


Do you suffer with nose bleeds?


Are you experiencing fevers?


If “yes” then for how long (days/ weeks/ months / years) have you had fevers?

3 weeks

Have you experienced any unintentional weight loss?


Have you ever experienced a seizure?


Do you experience bouts of facial paralysis?


Do you experience bouts of paralysis elsewhere in the body?


Have ever had a stroke?


When were you last in a malaria or dengue fever area?


Have you come into contact with cattle in the last year?


Does caffeine help the pain?


Are there any places on the head where the pain IMPROVES when finger pressure is applied?


If “yes” where on your head do you press to relieve pain?


Are there any places on the head where the pain GETS WORSE when finger pressure is applied?


Have you experienced past head or neck injuries or whiplash?


What is your minimum consumption of water a day?

Less than 2L

What is you maximum intake of water a day?

More than 1L

My preferred methods of contact are:



Phone Number

+** ** *** ****


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