* Mandatory Fields

Agents Info:

    *Name:  

      Agency:

    *Phone #:      *Fax #: 

    *E-mail address: 

Client Info:

    *Name:    

    *DOB:       *Height?      *Weight?  

    *Sex?       Male Female

If your client has headaches, please answer the following:

1. What is your clients actual diagnosis?     

2. When did your clients headaches first start?  

3. When was your clients last headache?     

4. How often does your clients headaches occur?  

5. The duration of your clients headaches?

            Intermittent       Continuous       Brief       Prolonged   

6. What part of your clients head is usually affected?

            Front       Back      Top      Sides  

7. Are your headaches associated with certain foods such as chocolate, coffee or MSG?

            Unknown Yes No   If yes, please give details: 

8. Indicate below any other associated symptoms?

            Vision (vision fields or double vision)       Numbness or tingling 

            Muscle weakness                                       Unsteadiness of limbs or staggering    

            Nausea, vomiting                                        Undue sleepiness       

            Dizziness, hearing loss                                Kidney disorder            

            High blood pressure                              

            Have fits or explosive behavior           

9. Is there a relationship between your clients headaches and any of the below?

            Allergies       Medications       Nervous tension      Menstrual cycle  

10. Has your client had any special diagnostic testing done for your

headaches?    Unknown Yes No

            If yes, please give details:  

11. Does your client have any other major health problem

(i.e. cancer,   heart, etc.)?   Unknown Yes No

            If yes, please explain: