A. Secure History

There was an error on your page. Please correct any required fields and submit again. Go to the first error
5. On a 0 to 10 scale, where 10 is emergency room level pain:
 What has your AVERAGE headache pain level been over the past few weeks?  *This question is required.
6. On a 0 to 10 scale, where 10 is emergency room level pain:
 What has your WORST headache pain level been over the past few weeks?  *This question is required.
7. On average, how many days per week (past few weeks) did you have a: 
Headache? *This question is required.
8. On average, how many days per week (past few weeks) did you have a: 
Migraine? *This question is required.
9. On average, how many days per week (past few weeks) did you have: 
Sinus pressure or nose stuffiness? *This question is required.
10. On average, how many days per week (past few weeks) did you have: 
Eye dryness or itchiness? *This question is required.
11. On average, how many days per week (past few weeks) did you have: 
Eye pain or pressure? *This question is required.
12. On average, how many days per week (past few weeks) did you have: 
Fullness or pressure in your ear(s)? *This question is required.
13. On average, how many days per week (past few weeks) did you have: 
Nausea? *This question is required.
14. On average, how many days per week (past few weeks) did you have: 
Lightheadedness? *This question is required.
15. On average, how many days per week (past few weeks) did you have: 
Jaw tightness, pain, or clicking? *This question is required.
16. On average, how many days per week (past few weeks) did you have: 
Pain or pressure in your teeth? *This question is required.
17. On average, how many days per week (past few weeks) did you have: 
Tightness in your upper shoulders?  *This question is required.
18. On average, how many days per week (past few weeks) did you have: 
Tightness in your shoulder blades or upper back? *This question is required.
19. On average, how many days per week (past few weeks) did you have: 
forearm, wrist or hand numbness symptoms, such as tingling, tightness, or pain? *This question is required.
20. Do you sleep on your stomach part of the night (most nights)?  *This question is required.
21. Do you sleep on your back part of the night (most nights)?  *This question is required.
22. How many hours are you down per night, whether sleeping or not? *This question is required.
23. On days that you don't awaken with extra-intense symptoms, by what time of the day do you generally notice your symptoms worsening?   *This question is required.
24. Please select any therapies that you have tried for relief of your symptoms up to this point. *This question is required.
25. Taking into account your ability to function and concentrate on the job, home, social life, ability to exercise, etc., what % of "your normal" would you say you're at? (100% means no limitations at all-  that you can do everything in your life without any problem) *This question is required.