Migraine Management Survey

Migraine Management

There are only a few steps to get started.

    Choose your Location

    What is your date of birth?

    Have you been diagnosed with migraine headaches by a doctor in person?

    Have you noticed any change in the location, type of pain, intensity or frequency of your headaches since your last visit with your doctor or over the last 1 year?

    Which type of treatment plans are you interested in?

    Tell us More

    Did you experience any side effects with previous headache treatments that would stop you from using them again?

    Tell us more about the side effects and the medication

    How often do you take medicine to treat headaches in a week?

    How many times a MONTH do you get a headache?

    Which side of the head are your headaches typically located? Select the one option that best applies to you.

    WHERE on the head are your headaches located?

    What does your headache pain feel like?

    How soon do your headaches reach maximum intensity?

    Without medicine, how long do your headaches usually last?

    Do you have an AURA with your headaches? (Change in vision lasting 5-60 minutes, occurs with headache, or followed by a headache within 1 hour. These can be tiny area of visual loss, seeing bright spots, geometric shapes, zigzagging lines, shooting stars)

    Which of the following symptoms do you get with your headaches? Select all that apply to you.

    Do you have any drug allergies?

    Tell us more

    Are you taking any other medicines?

    Include vitamins, herbs, and over-the-counter products, like pain relievers and sleep aids and WHY you are taking them.

    Anything else you would like us to know?

    How would you like to pay?

    upload emirates insurance details (if available)

    Insurance Card Image (Optiona

    Insurance provider:
    Insurance card no:
    Upload Insurance card:
    Feel free to leave any additional comments here:

    Billing and delivery details

    Google Map: (Please Share your Google Map Link)
    Delivery Location
    Neighborhood/Area:
    Street Name/No:
    Address Details:

    Personal Details

    Title:
    First Name: Last Name:
    Mobile Number: E-mail:

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