Questionnaire
Victoria - British Columbia - Canada - Vertigo- dizziness - motion sickness - TMJ problems - jaw pain - hip pelvic pain - Headaches - Migraines - Headache Relief - Migraine Relief - Migraine Headaches - Migraine Symptoms - Tension Headaches - Chronic Headaches - Alternative Medicine - Neck Pain - Lower Back Pain - Migraine Headaches - Migraine Symptoms

In what year did your headaches start?

Did they begin following an accident or injury?
Yes No

Have you had children?
Yes No

Are your headaches affected by your menstral cycle?
Yes No

How would you rate your diet?
Good Bad Average

Do you smoke?
Yes No

Do you have problems with vertigo, balance or motion sickness?
Yes No

Do you have problems with nausea and/or vomiting
Yes No

In this section, check the most common pattern and the number or numbers that best describe the levels of pain in each area, one being the mildest and five representing the most extreme.

Migraines/Headaches
Right Left Both None

Jaw pain, clenching and/or grinding your teeth
Right Left Both None

Neck pain, stiffness
Right Left Both None

Shoulders pain, stiffness
Right Left Both None

Upper arm pain, stiffness, numbness
Right Left Both None

Elbow pain, stiffness
Right Left Both None

Lower arm pain, stiffness, numbness
Right Left Both None

Wrist pain, stiffness, numbness
Right Left Both None

Upper back/shoulder blade area pain, stiffness
Right Left Both None

Middle back pain, stiffness
Right Left Both None

Lower back pain, stiffness
Right Left Both None

Hips/buttock pain, stiffness
Right Left Both None

Thigh pain, stiffness
Right Left Both None

Knee pain, stiffness
Right Left Both None

Calf pain, stiffness
Right Left Both None

Ankle pain
Right Left Both None

Foot pain (bottom of the foot)
Right Left Both None

Vision problems
Right Left Both None

Hearing Problems
Right Left Both None