Hit 6 Questionairre | Mountdale Migraine Centre

First Name*

Last Name*

Phone*

Email

Health Card #*

When you have headaches, how often is the pain severe?*

How often do headaches limit your ability to do usual daily activities including household work, work, school, or social activities?*

When you have a headache, how often do you wish you could lie down?*

In the past 4 weeks, how often have you felt too tired to do work or daily activities because of your headaches?*

In the past 4 weeks, how often have you felt fed up or irritated because of your headaches?*

In the past 4 weeks, how often did headaches limit your ability to concentrate on work or daily activities?*

How many days per month have you experienced any kind of symptoms of a mirgraine?*

Migraine Botox Questionnaire