Migraine New Patient Information Form

Name

First Name *

Middle *

Last Name *

Date of Birth

Month

Day

Year

Age

Sex

Male
Female

Address

Country

Address Line 1

City

State/Province *

Postal Code

Phone Number

Primary Care Provider & Address

Insurance Information

Transportation Barriers

Emergency Contact Name & Phone Number

please answer the following questions:

When did your migraine symptoms first start?

Month

Day

Year

2a. Have you had CT, MRI, lab tests or other diagnostic tests completed?

2b. What tests did you have completed and where?

3. Describe your migraine:

4. What associated symptoms do you have? Add note below if additional.

Light Sensitivity
Sound Sensitivity
Nausea
Visual Disturbance: Bright flashing lights, zigzag lines, blind spots, or stars.
Sensory/Motor Changes: Tingling, numbness, or "pins and needles" in the face, hands, or limbs.
Speech: Temporary difficulty with speech or finding words.
Dizziness, vertigo, or balance issues.
Ringing in the ears (tinnitus) or double vision.

5. What makes your symptoms worse?

6. What makes your symptoms improve?

7. How often do you get migraines? How long do they last?

8. What medications do you currently take for migraines?

Medical History

Please list all medications you are currently taking:

Please list all medications you are not currently taking, but have tried for symptom management:

Please list any other medical problems you have:

Please list all surgeries you have had and the year performed:

Please list any allergies:

Social History

Marital Staus

I live with

Alcohol Use

Tobacco Use/Exposure

Drug Use

Occupation—Note Job Title if Employed, Retirement or Disability Date

7ysmsc97jfxq

Any limitations to Perform Occupation/Home Tasks:

Additional information that you would like to share with our team to assist us with your treatment:

Today's Date

Migraine Clinic New Patient Form