888-201-7002 info@curemymigraine.com Corona, California
International Patients
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Before your visit

Medical questionnaire

Share all the needed information before setting your treatment appointment. Your answers help the doctor review your migraine or headache history in advance.

Personal details
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Gender *
Family history
Personal history
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Concussion / brain injury
Any surgical treatment
Your migraine
Side of migraine
Does the migraine radiate behind your eye(s)?
How often are you attacked by migraine?
Start point of the pain
Associated symptoms
Triggers
Do you have any dental fillings?
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Severity of pain (1–10)
Can you provide past tests (CT scan, MRI, nerve conduction, etc.)?
Willing to provide a written or recorded testimonial?

Your information is sent securely and reviewed only by the clinic. If you prefer, call 888-201-7002 to complete the questionnaire by phone.