SPECIALIST'S FORMSCountry and City City AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Name First Last Where in your head face and neck do you experience the pain? Forehead Left Temple Right Temple Behind the left eye Behind the right eye Back of the head/neck Teeth Jaw Around the ears Top of the head Near the nose All over How often do the attacks typically occur? Everyday Most days 2 to 3 times a week Once a week A few times a month Once a month A cluster of attacks Worse over menstruation Less than once a month Indicate the pain levels of the worst attacks on a scale of 1 to 10 where 1 is very mild and 10 is the worst pain imaginable. Which of the following are applicable to you? Throbbing pain Constant pain, not throbbing. Pain mostly/only on the left side of the head Pain mostly/only on the right side of the head Pain on both left and right sides of the head Stabbing pain Symptoms during attackDo any of the following occur during an attack? Red eye Tearing eye Blocked Nose Drooping eyelid Swollen eyelid Sore jaw or teeth Constricted (small) pupil on the headache side Other Do you experience any of the following? Dizziness Nausea Vomiting Phono-phobia (sensitivity to sound) Osmo-phobia (sensitivity to smells) Do you experience any of the following Painful or sensitive scalp Pain or discomfort brushing hair Pain or discomfort from very light contact with the scalp Pain or discomfort from wearing a hat Pain or discomfort when your head touches your pillow Are you experiencing any of the following? Drainage from the ear(s) Swollen or painful earlobe(s) Redness or tenderness of the ear Tinnitus (ringing in the ear) Feeling that the ear is full or stuffy Vertigo, dizziness. Loss of hearing Which of the following triggers your pain: Exercise Sun Dehydration Diet Alcohol Stress Food Skipping meals Sex Allergies Do you experience any visual disturbances before or during an attack? Blurred vision Loss of vision Double vision Appearance of rainbows Pain around the eye Flashing lights Tunnel vision Other visual disturbances Are any of the visual disturbances PERMANENT and NEVER seem to go away? Yes No Select any of the following if applicable: Shooting pain at the back of the throat Difficulty or pain in swallowing Sensation of a foreign object at back of the throat None of the above When did the headaches, migraines or cluster attacks first start? At what Age? How old are you now? (This simple information is critical for us to make decisions about which members of our team you may need.) Have you consulted with any of the following types of doctors or specialists for your headaches/migraines? (We do not want to repeat anything and we may need information from these specialists)Please tick the ones you have seen. Neurologist Neurosurgeon Plastic Surgeon Physiotherapist Dentist Maxillo Facial Surgeon Ear, Nose and Throat Specialist Optometrist Gynaecologist Psychiatrist Psychologist Nutritionist Chiropractor General Practitioner Other Have you undergone any of the following tests or procedures for your migraines / headaches? MRI Scan CT Scan Lumbar Puncture Surgery Are there any other tests or procedures you have undergone, or other specialists you have seen that are not listed above?How long do the attacks typically last? How many days in the month are you 100% pain free? Movement of the pain.Does the pain move or spread? Please describe in detail. The more information we have the better.Is there any trauma that you recall that could be linked to the onset of your headaches?Physical injuries, accidents, whiplash, illness? What about life events like crime, divorce, bereavement, or psychological trauma?Did your headaches manifest subsequent to having a surgical procedure? Yes No HiddenSection BreakIf 'yes', please state when, and which procedure was performed and what you experienced.Section BreakHas the pain changed over time? Yes No HiddenSection BreakHow has the pain changed?HiddenSection BreakHiddenAre you experiencing any dental pain or painful teeth? Yes No Do you grind your teeth? Yes No When you bite or clench your teeth, are the any painful points or notable pressure points? Yes No HiddenSection BreakIf 'yes', please describe:HiddenSection BreakHave you had any of your wisdom teeth removed? Yes No Do you have any difficulty or discomfort opening your mouth? Yes No Do you have dentures? Yes - Partial Yes - Full No HiddenSection BreakRate the comfort level: 1 - Dentures feel natural 2 - There is a physical awareness, but no discomfort of the dentures 3 - Dentures are slightly loose 4 - Dentures feel a little tight 5 - Dentures cause discomfort while speaking/eating 6 - Dentures cause physical pain Have you experienced any change in your headache related to your dentures? Yes No HiddenSection BreakDo you experience any jaw clicking? Yes No Do you experience any pain or stiffness in the jaw while eating/chewing? Yes No Please list any medications you are currently taking. Click the "+" sign to enter another line:Please list ALL medications, headache / migraine related or for any other conditions, prescription or over the counter. This is vitally important information for our team. Name of MedicationDosageNumber of Times Per DayRelated Condition We aim to reduce medication intake by reducing pain but for diagnostic purposes we need to know if you have you tried any of the following medications? Magnesium tablets Maxalt Imigran / Imitrex Indomethacin Cafergot Dihydroergotamine (DHE) Sumatriptan Ergotamine Codene / Adcodol Have you experienced any of the following: Need larger doses of medication to achieve the same result Pain returns shortly after the migraine medication wears off Medication worked in the beginning but after needing larger doses it stopped working Downward spiral into constant pain and medication dependence HiddenSection BreakDo you use oral contraceptives? Yes No Is your pain correlated with hormonal cycles? Yes No Not sure Are headaches worse with any of the following: Mensturation Ovulation Hormone Replacement Therapy Not Applicable Do you suffer with nose bleeds? Yes No Are you experiencing fevers? Yes No If "yes" then for how long (days / weeks / months / years ) have you had fevers? HiddenDo you experience bouts of confusion? Yes No Have you experienced any unintentional weight loss? Yes No HiddenSection BreakIf so, please describe:HiddenSection BreakHave you ever experienced a seizure? Yes No HiddenSection BreakIf so, please describe:HiddenSection BreakDo you experience bouts of facial paralysis? Yes No Do you experience bouts of paralysis elsewhere in the body? Yes No HiddenSection BreakPlease describe where the paralysis occurs and if there are any warning signs you get before the paralysis:HiddenSection BreakHave ever had a stroke? Yes No If YES please describe in detail and include the approximate date or dates.When were you last in a malaria or dengue fever area? Have you come into contact with cattle in the last year? Yes No HiddenHave you recently experienced an unexplained loss of appetite? Yes No Does caffeine help the pain? Yes No Are there any places on the head where the pain IMPROVES when finger pressure is applied? Yes No If "Yes" where on your head do you press to relieve pain? Temple Back of the head / neck Behind the ear Other Are there any places on the head where the pain GETS WORSE when finger pressure is applied? Yes No If "Yes" please elaborateHave you experienced past head or neck injuries or whiplash?If so please describe the nature of the injury (e.g. fracture) and when the injury occurred.What is your minimum consumption of water a day? Less than 1L Less than 2L Less than 3L What is you maximum intake of water a day? More than 1L More than 2L More than 3L Please list any other medical conditions from which you suffer.My preferred methods of contact are: E-mail Telephone Whatsapp Facebook Email Email* Telephone NumberTelephone Number*WhatsApp NumberWhatsApp Number*I am interested in: Consultation and treatment free information only If you have any medical records you would like to upload for the team please do so here.Max. file size: 64 MB.MRI migraine specialists will treat patient's only when medical information indicates a high probability of successful outcome. There is no cost to complete this form, hear back from us, and engage with our team. MRI does not store ANY patient data online, your information is converted to PDF for our specialists and deleted from the internet providing complete security for medical records. We will never share any of your information with anyone outside of MRI. Our specialists review your detailed data free of charge and provide proforma quotations before any consultations or commitments.
