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Secure History- Head/Neck

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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? 
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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? 
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On average, how many days per week (past few weeks) did you have a: 
Headache?
On average, how many days per week (past few weeks) did you have a: 
Migraine?
On average, how many days per week (past few weeks) did you have: 
Sinus pressure or nose stuffiness?
On average, how many days per week (past few weeks) did you have: 
Eye dryness or itchiness?
On average, how many days per week (past few weeks) did you have: 
Eye pain or pressure?
On average, how many days per week (past few weeks) did you have: 
Fullness or pressure in your ear(s)?
On average, how many days per week (past few weeks) did you have: 
Nausea?
On average, how many days per week (past few weeks) did you have: 
Lightheadedness?
On average, how many days per week (past few weeks) did you have: 
Jaw tightness, pain, or clicking?
On average, how many days per week (past few weeks) did you have: 
Pain or pressure in your teeth?
On average, how many days per week (past few weeks) did you have: 
Tightness in your upper shoulders? 
On average, how many days per week (past few weeks) did you have: 
Tightness in your shoulder blades or upper back?
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?
Do you sleep on your stomach part of the night (most nights)? 
Do you sleep on your back part of the night (most nights)? 
How many hours are you down per night, whether sleeping or not?
Are your symptoms generally Better or Worse in the morning, when you wake up?
On days that you don't awaken with extra-intense symptoms, by what time of the day do you generally notice your symptoms worsening?  
Which headache, migraine or other related conditions have you been diagnosed with in the past or do you believe you have?
Please select any therapies that you have tried for relief of your symptoms up to this point.
Please select each one of these that's true for you in dealing with your headache/migraine problem:
(These help Dr. Turner target specific functional issues) *This question is required.
Would you like our receptionist to schedule for you a quick & free phone session with Dr. Jeff Turner PT, DPT, Cert. MDT before Advanced Treatment so that you can discuss your symptom patterns with Dr. Turner? (Recommended)
How did you first find us?
Do you live in Texas? *This question is required.
1. Would like for us to check on your insurance benefits for this System?