A. Symptom History

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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: 
Arm or hand numbness, tingling, or tightness? *This question is required.
10. On average, how many days per week (past few weeks) did you have: 
Sinus pressure or nose stuffiness? *This question is required.
11. On average, how many days per week (past few weeks) did you have: 
Eye dryness or itchiness? *This question is required.
12. On average, how many days per week (past few weeks) did you have: 
Eye pain or pressure? *This question is required.
13. On average, how many days per week (past few weeks) did you have: 
Fullness or pressure in your ear(s)? *This question is required.
14. On average, how many days per week (past few weeks) did you have: 
Nausea? *This question is required.
15. On average, how many days per week (past few weeks) did you have: 
Lightheadedness? *This question is required.
16. On average, how many days per week (past few weeks) did you have: 
Jaw tightness, pain, or clicking? *This question is required.
17. On average, how many days per week (past few weeks) did you have: 
Pain or pressure in your teeth? *This question is required.
18. On average, how many days per week (past few weeks) did you have: 
Tightness in your upper shoulders? *This question is required.
19. 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.
22. In the past few weeks, what percent of the day would you say you had any symptoms at all in your head or your face? (100% means that you had symptoms all day, even if low intensity) *This question is required.
23. Do you sleep on your stomach part of the night (most nights)?  *This question is required.
24. Do you sleep on your back part of the night (most nights)?  *This question is required.
25. When you have headaches, how often is the pain severe? *This question is required.
26. How often do headaches limit your ability to do usual daily activities, including household work, work, school, or social activities? *This question is required.
27. When you have a headache, how often do you wish you could lie down? *This question is required.
28. In the past 4 weeks, how often have you felt fed up or irritated because of your headaches? *This question is required.
29. In the past 4 weeks, how often have you felt too tired to do work or daily activities because of your headaches? *This question is required.
30. In the past 4 weeks, how often did headaches limit your ability to concentrate on work or daily activities? *This question is required.
31. 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.
32. How many hours are you down per night, whether sleeping or not? *This question is required.
33. In the morning, before you get out of bed, are your symptoms generally better or worse?  *This question is required.
34. 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.
35. On average, how many days per week in the past few weeks did you have low back pain (around your belt line or below)? *This question is required.
36. On average, how many days per week in the past few weeks did you have buttock, hip, leg, calf, or foot symptoms? *This question is required.
37. Are you on (or seeking) disability benefits for your problem? *This question is required.
38. Are you seeking legal counsel, such as a lawyer or attorney for issues related to these problems (like after a car accident, work injury, etc.)? *This question is required.
39. Please select any therapies that you have tried for relief of your symptoms up to this point. *This question is required.
40. Please select any triggers that you have, if applicable.
41. Have you seen a medical practitioner (Dr. or P.A.) in the past year for this problem? *This question is required.
42. Did this practitioner refer you to us? *This question is required.
42. Are you currently working with an attorney in relation to this problem (like from a car accident or fall, for instance)? *This question is required.
43. Are you seeking Social Security Disability for this condition? *This question is required.