Migraine Botox Questionnaire First Name*Last Name*Phone*Email Health Card #*When you have headaches, how often is the pain severe?*NeverRarelySometimesVery OftenAlwaysHow often do headaches limit your ability to do usual daily activities including household work, work, school, or social activities?*NeverRarelySometimesVery OftenAlwaysWhen you have a headache, how often do you wish you could lie down?*NeverRarelySometimesVery OftenAlwaysIn the past 4 weeks, how often have you felt too tired to do work or daily activities because of your headaches?*NeverRarelySometimesVery OftenAlwaysIn the past 4 weeks, how often have you felt fed up or irritated because of your headaches?*NeverRarelySometimesVery OftenAlwaysIn the past 4 weeks, how often did headaches limit your ability to concentrate on work or daily activities?*NeverRarelySometimesVery OftenAlwaysHow many days per month have you experienced any kind of symptoms of a mirgraine?*5 or lessbetween 6 and 10between 10 and 1920 or more