1- Secure History- Head/Neck

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? 

0	1	2	3	4	5	6	7	8	9	10
0	1	2	3	4	5	6	7	8	9	10

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? 

0	1	2	3	4	5	6	7	8	9	10
0	1	2	3	4	5	6	7	8	9	10

Over the past few weeks, how many days a week did you have a headache?

• 0
• 1
• 2
• 3
• 4
• 5
• 6
• 7

Over the past few weeks, how many days a week did you have a migraine?

• 0
• 1
• 2
• 3
• 4
• 5
• 6
• 7

Over the past few weeks, how many days a week did you have sinus pressure or nose stuffiness?

• 0
• 1
• 2
• 3
• 4
• 5
• 6
• 7

Over the past few weeks, how many days a week did you have eye pain or pressure?

• 0
• 1
• 2
• 3
• 4
• 5
• 6
• 7

Over the past few weeks, how many days a week did you have symptoms in your forehead or temples?

• 0
• 1
• 2
• 3
• 4
• 5
• 6
• 7

Over the past few weeks, how many days a week did you have jaw tightness, pain, or clicking?

• 0
• 1
• 2
• 3
• 4
• 5
• 6
• 7

Over the past few weeks, how many days a week did you have fullness or pressure in your ear(s)?

• 0
• 1
• 2
• 3
• 4
• 5
• 6
• 7

Over the past few weeks, how many days a week did you have symptoms in the back of your head or base of your skull?

• 0
• 1
• 2
• 3
• 4
• 5
• 6
• 7

Over the past few weeks, how many days a week did you have nausea?

• 0
• 1
• 2
• 3
• 4
• 5
• 6
• 7

Over the past few weeks, how many days a week did you have lightheadedness, dizziness, or vertigo?

• 0
• 1
• 2
• 3
• 4
• 5
• 6
• 7

Over the past few weeks, how many days a week did you have tightness in your upper shoulders (between your neck and shoulders)? 

• 0
• 1
• 2
• 3
• 4
• 5
• 6
• 7

Over the past few weeks, how many days a week did you have tightness down in your shoulder blades or upper back?

• 0
• 1
• 2
• 3
• 4
• 5
• 6
• 7

Over the past few weeks, how many days a week did you have forearm, wrist or hand symptoms, such as numbness, tingling, tightness, weakness, incoordination, or pain?

• 0
• 1
• 2
• 3
• 4
• 5
• 6
• 7

Do you usually sleep on your stomach for at least a part of the night, most nights?

• Never
• 25% of the night
• 50% of the night
• 75% of the night
• 100% of the night

Do you usually sleep on your back for at least a part of the night, most nights?

• Never
• 25% of the night
• 50% of the night
• 75% of the night
• 100% of the night

How many hours do you spend lying down each night, whether you are sleeping or not?

• <4
• 4
• 4 1/2
• 5
• 5 1/2
• 6
• 6 1/2
• 7
• 7 1/2
• 8
• more than 8 hours

Are your symptoms generally Better or Worse in the morning, when you wake up?

• Generally Better
• Generally Worse
• There's No Difference

How many hours does it take for your pain or symptoms to increase on days when you don't wake up feeling terrible?

   

• N/A
• 2
• 4
• 6
• 8
• 10
• 12
• 14

What headache, migraine, or related conditions have you been diagnosed with or believe you have?

• I have no idea
• Occipital Neuralgia / Occipital Headache
• Chronic Migraine with Aura
• Chronic Migraine without Aura
• Menstrual Migraine
• Cluster Headache
• Ocular Migraine or Ophthalmic Migraine ("Eye" migraine)
• Abdominal Migraine / IBS
• Hemiplegic Migraine
• Trigeminal Neuralgia
• Status Migrainosus (a migraine attack that lasts longer than 72 hours)
• Radiculopathy (arm, forearm or hand symptoms like numbness or tingling)
• Other - Write In Please enter an 'other' value for this selection.

Please select any therapies you have tried to relieve your symptoms up to this point.

• None. (I've not pursued other therapies for these symptoms.)
• Prescription medications, or very frequent over-the-counter medications
• I've tried a preventive, such as Nurtec, Ubrelvy, Qulipta, Vyepti, propranolol, topamax, etc.
• Neurologist
• Ear/Nose/Throat (ENT) Doctor or Neuro-otologist
• Ophthalmologist (eye Doctor) for eye pain or dry eye
• Gastro-enterologist (stomach Doctor) for nausea, reflux, bowel issues, etc.
• Dentist (e.g., for TMJ issues)
• Pain management injection or intervention (e.g., occipital nerve block, radiofrequency burning/ablation, cutting head or facial nerves)
• Botox
• Biofeedback, psychological counseling (e.g., stress)
• Acupuncture
• Chiropractic
• Massage Therapy
• Physical Therapy
• Surgically-implanted nerve stimulator (e.g., Omega or Reed Procedure, etc.)

Please select each of the following that apply to you when dealing with headaches/migraines. This helps us identify specific functional issues. *This question is required.

• My sleep is disturbed.
• I feel fed up and irritated, and it affects my mood.
• I feel too tired to do work or daily activities.
• I'm missing out on quality time with my family/friends.
• My ability to focus and concentrate on work or daily activities is limited.
• I'm less productive at work or school.
• Extra stress makes my problem worse.
• Changes in weather (barometric pressure) worsens my symptoms.
• I need to lie down a lot.
• I can't exercise like I want to.
• I can't drive my car as long as I want.
• I can hardly do any recreational activities or social events.
• I can't plan trips in advance, due to random pain attacks.
• I have intolerable side effects from medications or injections.
• My work is threatened because of low productivity or for unexcused absences.
• Bright lights bother me.
• Loud sounds bother me.
• Strong smells bother me.
• I spend a lot of time and money seeking ongoing symptom relief (e.g., copays, medications, massage, Chiropractic, supplements, etc.).
• Other - Write In Please enter an 'other' value for this selection.

Please indicate what percentage of your usual capacity you are currently functioning at. You should take into consideration your ability to work, focus, engage in social activities, perform household tasks, and exercise. A score of 100% implies that you have no limitations and can perform all your daily activities without any difficulty.

• 0%
• 10%
• 20%
• 30%
• 40%
• 50%
• 60%
• 70%
• 80%
• 90%
• 100%

1. In the past week, when you had a headache, how often was the pain severe? *This question is required.

• Never
• Rarely
• Sometimes
• Very Often
• Always

2. In the past week, how often did headaches limit your ability to do usual daily activities including household work, work, school, or social activities? *This question is required.

• Never
• Rarely
• Sometimes
• Very Often
• Always

3. In the past week, when you had a headache, how often did you wish you could lie down? *This question is required.

• Never
• Rarely
• Sometimes
• Very Often
• Always

4. In the past week, how often have you felt too tired to do work or daily activities because of your headaches? *This question is required.

• Never
• Rarely
• Sometimes
• Very Often
• Always

5. In the past week, how often have you felt fed up or irritated because of your headaches? *This question is required.

• Never
• Rarely
• Sometimes
• Very Often
• Always

6. In the past week, how often did headaches limit your ability to concentrate on work or daily activities? *This question is required.

• Never
• Rarely
• Sometimes
• Very Often
• Always

Do you live in Texas? *This question is required.

• Yes
• No

Have you seen us as a client before?

• Yes
• No

Is this associated with a new injury that we need to be aware of (for instance, a car accident, fall, etc.)?

• Yes
• No

How important is it to you to achieve lasting relief from these problems compared to managing pain? This question helps us better understand and respect your mindset and expectations regarding our approach.

Not That Important	Somewhat Important	Important	Very Important
Not That Important	Somewhat Important	Important	Very Important

(OPTIONAL): How did you first find us?

• Physician/P.A. Referral
• Google search
• Google search ad
• Bing search
• Bing search ad
• YouTube
• YouTube ad
• Facebook
• Facebook Ad
• Instagram
• Twitter
• Quora
• Reddit
• Yelp
• LinkedIn
• Pinterest
• Email
• Other (not listed)