Chronic Headache & Migraine – Patient Forms

Start Your Journey Toward Relief

Before booking your appointment, please complete the form below. This ensures our team has the information needed to provide you with personalized and effective care. Once completed, you’ll be directed to our booking portal.

Headache & Migraine Questionnaire

Name

First Name

Last Name

Phone

(###)

###

####

What triggers your headaches/migraines? (tick all that apply)

Stress

Lack of sleep

Hormonal changes

Certain foods/drinks

Bright lights or strong smells

Others

When did your headaches/migraines first start?

How often do you experience them? (e.g. daily, weekly, monthly)

Where is the pain located?

How would you rate the average pain on a scale of 1–10?

Do you experience warning signs before a migraine (e.g. aura, visual disturbances, nausea)?

Have you been formally diagnosed with migraines or chronic headaches?

Are you currently taking any medications?

What treatments or medications have you tried?

Preferred Date

YYYY

Is there anything else you'd like us to know?

Referral Form – For Healthcare Providers

Referring Doctor Name

First Name

Last Name

Clinic Name

Phone

(###)

###

####

Clinic Fax

(###)

###

####

Clinic Email

(###)

###

####

Patient Name

Patient Contact Number

Patient Email

Reason for Referral (brief clinical notes or suspected diagnosis)

Relevant Medical History

Current Medications

Has the patient previously seen a neurologist or pain specialist?

Preferred Date

YYYY

Fax Number

All patient information is kept confidential and handled in accordance with Canadian privacy laws and healthcare data regulations (including PHIPA and PIPEDA).

Chronic Headache & Migraine – Patient Forms

Start Your Journey Toward Relief

Headache & Migraine Questionnaire

Referral Form – For Healthcare Providers

HDMD Medical Services

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