First Name: Surname: Street City Country Telephone Email Occupation Gender Year of birth 1. How old were you when you first had a migraine attack? 2. Do you know what caused or triggered it then? YesNo 3. Do other members of your family suffer from migraines? YesNo 4. How many days a month do you have "normal" headaches? 5. How many days a month do you suffer from migraines? 6. How long does your migraine last on average? less than 2 hours3 - 4 hrs5 - 12 hrs12 - 24 hrsmore than 24 hrsmore than 1 week 7. How painful are your migraine attacks?(On a scale of 1-10, with 1 being no pain and 10 being excruciating pain) 8. Where do you experience the majority of your migraine-related pain? behind your eye (left)above your eyebrow (left)on the temple (left)on the back of your head (left)nosebehind your eye (right)above your eyebrow (right)on the temple (right)on the back of your head (right) distribution (in %) per side: (Please estimate a percentage) left…….% right………% 9. During a migraine attack, do you usually experience pressure or pain in the nose? alwayssometimesnever 10. Is your migraine related to changes in the weather? alwayssometimesnever 11. Do you wake up at night due to migraine pain? alwaysoftensometimesnever 12. Have you ever suffered one or more of the following symptoms before or during a migraine attack? before VomitingVomiting combined with diarrhoeaDiarrhoea (without vomiting)Watering eyesDizzinessSwelling of the eyelidsProblems concentratingNumbness in the skinSight disorders (double vision, flashes, zigzag lines,blurred vision, other)NauseaSensitivity to lightSensitivity to noiseMuscle weaknessIncreased sweatingSpeech defectsLoss of consciousnes (fainting)Increased nasal secretionLow blood sugar during VomitingVomiting combined with diarrhoeaDiarrhoea (without vomiting)Watering eyesDizzinessSwelling of the eyelidsProblems concentratingNumbness in the skinSight disorders (double vision, flashes, zigzag lines,blurred vision, other)NauseaSensitivity to lightSensitivity to noiseMuscle weaknessIncreased sweatingSpeech defectsLoss of consciousnes (fainting)Increased nasal secretionLow blood sugar 13. Do you suffer from increased sensitivity to pain before or during a migraine attack ? My hair 'feels' painfulI have to wear my hair down or put it up (remove hairclips, hairbands,etc.)I no longer use hair curlers/straightenersI sometimes let my hair float in the bath to get some relief from my headacheI have to cut my long hair off in order to reduce the weight on my scalpThe feeling of rain/showers/water falling on my head is painfulI find it painful to wear anything on my head (e.g. hat)Eye shadow is uncomfortableI cannot wear headphones during my migraine attackDuring a migraine attack, I find wearing blankets uncomfortableMy fingers feel painful on contact with everyday itemsMy sensitivity to pain has increased over recent years 14. What gives you relief during a migraine attack? RestVomitingSport/exerciseSleepDarknessTelevisionWarm waterCold waterMusicMassageReadingPain-killers 15. What triggers or exacerbates (worsens) your migraine ? NoisePhysical exertionIrregular or late mealsCertain foodsChange of weatherSmellsFatigue (tiredness)Too much or too little sleepLightStressCoughingPain-killers 16. If you are a women, is/was your migraine affected by the following? If so, in what way? Menstruation (monthly periods) ImprovementDeteriorationno change The contraceptive Pill ImprovementDeteriorationno change Hormone tablets (eg HRT for menopause) ImprovementDeteriorationno change Pregnancy Improvement 17. Have you ever had one of the following medical problems? High blood pressureCoronary diseaseStomach ulcersAsthmaDepressionAllergiesEpilepsyStrokeSkin problems/diseases 18. Have you ever been examined and treated by a doctor for your migraines? YesNo 19. Have you had any of the following tests for your migraine? EEG (electroencephalogram)CT (Computer Tomography)MRTBlood testsX-rayECG 20. Do you take medications for your migraines? YesNo 21. Do these treatments help you? alwaysoftensometimesnever 22. How many times did you see a doctor last year about your migraines? none1 - 45 - 10more than 10 23. How many different doctors did you see last year about your migraines? 24. How many different doctors did you see last year about your migraines? Music to relaxMuscle relaxationExerciseComplementary medicineAdminister local pain relief (gel, cream etc)Medication 25. How many days were you absent from work last year due to migraines? less than 3 days4 - 7 days8 - 14 days15 - 21 daysmore than 3 weeks 26. Which of the following approaches have you used in the past? HomoeopathyPsychotherapyRelaxation exercisesMigraine cushionsHypnosisHerbal remediesAcupunctureOsteopathyOther 27. In the past, have you ever had an injection with botulinum toxin type A (commonly marketed as Botox)? YesNo 28. Please provide any further information about your migraine symptoms or treatment that you think might be relevant: 29. How did you learn about Op Dr Ufuk Askeroglu? newspaper / magazinetelevision / radioother patientsinternetother
