Migraine & Headaches

Pre-Treatment
Questionnaire

Please complete this form prior to your first appointment with Dr. Elena Ocher and Dr. Kaveh Alizadeh. Your responses help us determine if you are a surgical candidate and allow us to create a treatment program specific to you.

* Indicates required field

Personal Information

First Name *

Last Name *

Phone Number *

Date of Birth *

Gender *

Occupation *

Health Insurance Co. *

Medical History

Have you ever had a head or neck injury requiring medical treatment? *

Yes No

Describe head or neck injury that required medical treatment

List all past tests you have had

List all past treatments for your migraines

Medications

Are you taking any prescription medications to treat your migraines? *

Yes No

List prescription medications used to treat your migraines

Are you taking any over-the-counter drugs to treat your migraines? *

Yes No

List over-the-counter drugs used to treat your migraines

Quality of Life

To what extent do your migraines affect your quality of life? *

Extremely Moderately Very little Not at all

Fields marked * are required. Your information is kept strictly confidential and used solely to prepare your treatment consultation.

Thank you. Your questionnaire has been received. We will review your responses and contact you to schedule your consultation.

Pre-Treatment
Questionnaire

Personal Information

Frequency & Duration

Pain & Onset

Associated Symptoms

Medical History

Medications

Quality of Life

Pre-TreatmentQuestionnaire

Personal Information

Frequency & Duration

Pain & Onset

Associated Symptoms

Medical History

Medications

Quality of Life

Pre-Treatment
Questionnaire