Migraine Botox Questionnaire First Name* Last Name* Phone*Email Health Card #* When you have headaches, how often is the pain severe?* Never Rarely Sometimes Very Often Always How often do headaches limit your ability to do usual daily activities including household work, work, school, or social activities?* Never Rarely Sometimes Very Often Always When you have a headache, how often do you wish you could lie down?* Never Rarely Sometimes Very Often Always In the past 4 weeks, how often have you felt too tired to do work or daily activities because of your headaches?* Never Rarely Sometimes Very Often Always In the past 4 weeks, how often have you felt fed up or irritated because of your headaches?* Never Rarely Sometimes Very Often Always In the past 4 weeks, how often did headaches limit your ability to concentrate on work or daily activities?* Never Rarely Sometimes Very Often Always How many days per month have you experienced any kind of symptoms of a mirgraine?* 5 or less between 6 and 10 between 10 and 19 20 or more CAPTCHA
