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Headache/Migraine Online Consultation Form

Please fill out the following information and press the SUBMIT button below. We will receive and review the information you submit as promptly as we can. All information you submit in this form will be kept strictly confidential. Please check out our Privacy Policy for further information.

Personal Information:

First (Given) Name: Last (Family) Name:
E-Mail: Date of Birth: //  (day/month/year)
Gender:  Male      Female Occupation: 
Marital Status:

Full Address (Including Country):

Weight: kg     or    lb
Height: cm     or     feet inch
Are you a vegetarian? Yes   No
Would you consider taking fossil for medication? Yes   No
Or insects? Yes   No

Diagnostic Information:

Regular Blood Pressure mmHg/mmHg or    kPa/kPa
Regular Pulse Rate (Heart Beat): beats per minute
Describe the nature of the painDistending  Stabbing  Fixed  Dull  Heavy  Hollow

How else do you describe your pain?

Pick the closest location of the pain:

Or describe more on the location of your headache:

Main Complaint: (Describes your headache/migraine in your own words. Any accompanying symptoms? Dizziness? Nausea? Become worse after overwork? Any particular time it hits? and how long it has been? And etc.)
History and Medication of Main Complaint: (How it started? Its development. Courses of treatments, and etc.)
Other Complaints: (Such as appetite, sleep quality, life styles, urine color and frequency, the bowel movements, mental conditions, energy level, and the physical symptoms: Aching pain in the loins and kness? Taste of mouth?)
History and Medication of Other Complaints:
GP's Diagnosis: and his/her advice:
What medication are you having now? And their dosages? No Yes
Have you had any clinical laboratory/physical examinations (Blood, urine, X-ray, CT?)  Any abnormalities? What are the results? No Yes
Are you allergic to anything? No Yes
Are any of your family members having the same problems? No Yes

Questions for female only:

Are you pregnant? Yes. How many months? Condition of Pregnancy:
No. Are you expecting to get pregnant? Yes  No
History of Menstrual Period: Info needed are how long the period, the cycle are. The quantity, presence of blood clots, color of menstruation, presence of PMS/PMT, and color and quantity of discharge, and etc.)

Does your headache/migraine become worse before/during/after your period?  

Yes           No

Are you having menopause? (If you're from 45 to 55 years old and have delayed menstrual cycle, short in period, scanty in amount; or sometimes disorder of menstrual cycle, long in period, profuse menstruation. Most probably you're going through menopause.) No Yes. What are your symptoms?

Anything else you believe is related or other things you wish to tell us:

Please fill out the form as detailed as possible especially the subjective parts about your illness. Vague descriptions with lack of details will only result in improper diagnosis. After you are finished with it, click 'Submit' below: