Patient Data SecurityMRI will administer your file free of charge only if our specialists and administrators agree that there is a high probability of a 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 before any consultations or commitments.My preferred methods of contact are: E-mail Telephone Whatsapp Facebook Name First Last HiddenHiddenCountry 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 Email Phone NumberHiddenHiddenWhen did the headaches, migraines or cluster attacks first start? At what Age? How old are you now? Have you consulted with any of the following types of doctors or specialists for your migraines?Please tick the ones you have seen. Neurologist Neurosurgeon Plastic Surgeon Physiotherapist Dentist Prosthodontist Maxillo Facial Surgeon Ear, Nose and Throat Specialist Optometrist Ophthamologist Physician Gynaecologist Psychiatrist Psychologist Nutritionist Acupuncturist Chiropractor Other Have you undergone any of the following? MRI Scan Blood tests CT Scan X-rays Lumbar Puncture EEG ECG EMG Electromyogrpah Helicobacter Pylori Eye examination Other HiddenAny other testing you have undergone, or other specialists you have seen not listed above?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 Worse over menstruation Less than once a month How long do the attacks typically last? How many days in a month are you 100% headache freeIndicate your pain levels on a scale of 1 to 10 where 1 is very mild and 10 is the worst pain you could imagine. Where in your head face and neck do you experience the pain? Does the pain move or spread? Is it throbbing pain, constant pressure, painful to touch, stabbing pain? The more information we have the better. 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 Movement of the pain.Does the pain move or spread? Is it throbbing pain, constant pressure, painful to touch, stabbing pain? 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 which procedure was performed and what you experienced.Did your headache / migraine pain begin subsequent to being bitten by an insect?YesNoIf "Yes" please describe in detail:When were you last in a malaria area? HiddenSection 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 HiddenSection BreakIf 'yes', please describe what you are experiencing:HiddenSection BreakDo 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 Please list any medications you are currently taking. Click the "+" sign to enter another line:Please disclose all medications, headache-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 Have you tried any of the following? Magnesium tablets Maxalt Imigran / Imitrex Indomethecin Cafergot Dihydroergotamine (DHE) Sumatriptan 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 Please list any medications that you are concerned about, or about which you want to know more about the side effects:HiddenSection BreakHiddenSection BreakDo you use oral contraceptives? Yes No Do you feel that there is a hormonal component to your pain?YesNoNot sureIf "Yes" please describe this hormonal component:Do you suffer with nose bleeds? Yes No HiddenDoes the below image match your pain distribution? The image does NOT AT ALL MATCH my pain distribution I SELDOM experience pain in the areas indicate on the image I OFTEN experience pain in the areas indicate on the images The image PERFECTLY MATCHES the areas I experience pain in Do you have any PERMANENT visual disturbances? Blurred vision Loss of vision Double vision Appearance of rainbows around lights Pain in the eye Pain around the eye None of the above Are you experiencing fevers? Yes No If "Yes" then when did the fevers first start? How long ago in weeks/months/years? Do you experience any pain or stiffness in the jaw while eating/chewing? Yes No 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 BreakIf you have experienced a seizure was the first one quite recent? Yes No Do 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 predomes to the paralysis:HiddenSection BreakHave ever had a stroke? Yes No If YES please describe in detail and include the approximate date or dates.HiddenHave you recently experienced an unexplained loss of appetite? 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 Are you experiencing any of the following? Drainage from the ear(s) Swollen or painful earlobe(s) Redness or tenderness of the ear None of the above Symptoms during attackDo any of the following occur during an attack? Red eye Tears Blocked Nose Drooping eyelid Swollen eyelid Sore jaw or teeth Constricted (small) pupil on the headache side Other Please elaborate what other symptoms you experience:HiddenSection BreakHiddenSection BreakSelect which of the following secondary symptoms (if any) you experience: Dizziness Nausea Vomiting Photo-phobia (sensitivity to light) Blurred vision Phono-phobia (sensitivity to sound) Osmo-phobia (sensitivity to smells) Tinnitus (ringing in the ears) Other Not Applicable HiddenSection BreakPlease elaborate what other secondary symptoms you experience:HiddenSection BreakHiddenSection BreakHiddenSection BreakWhich of the following triggers your pain: Exercise Sun Dehydration Diet Alcohol Stress Food Skipping meals Sex Other Not Applicable HiddenSection BreakPlease elaborate if 'other':HiddenSection BreakDoes 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 If "other" please elaborate:Are there any places on the head where the pain GETS WORSE when finger pressure is applied? Yes No If "Yes" please elaborateDo 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 Have 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.Have you come in contact with cattle and were any blood tests performed with regard thereto?Are headaches worse with any of the following: Mensturation Ovulation Oral Contraceptives Hormone Replacement Therapy Other Not Applicable Do you have any thoughts about what may be causing your headaches?Have you experienced any major or minor changes to your headaches and if so how recently?What is your minimum consumption of water a day?Please try to keep you information about the intake of water as accurate as possible. Please note Juice, coffee, tea etc. do not constitute water intake. Less than 1L Less than 2L Less than 3L What is you maximum intake of water a day?Please try to keep you information about the intake of water as accurate as possible. Please note Juice, coffee, tea etc. do not constitute water intake. More than 1L More than 2L More than 3L HiddenSection BreakPlease list any other medical conditions from which you suffer.HiddenSection BreakIf you have any medical records you would like to upload for the team please do so here.Max. file size: 32 MB.
