Research

Patient Demographics

Patient Name *

Patient Age

Patient Sex

Patient Telephone *

Patient Home City, State

Patient History

Current Diamond Headache Clinic Patient?

Headache Diagnosis by Physician?

All Headache Diagnosis

Headache begin before age 50?

Years with Headache

Last 3 Months, Average Monthly Moderate/ Severe Headache?

Last 3 Months, Average Monthly Moderate/ Severe Headache Days?

Last 3 Months, Average Monthly Headache Free Days?

Last 3 Months, Average Monthly Duration of Moderate/ Severe Headaches?

Dominant Area(s) of the Moderate/ Severe Headaches?

Auras (Visual Disturbances) with Headaches?

Any Other Symptoms with Headaches?

All Current Medications (Prescribed, Over the Counter, Supplements)

All Other Current and Past Medical Condition

Allergy or Allergic Reactions

Females: Birth Control Method

Patient Availbility

Available Hours per Week for Study

Available Months for Study

Available for Study Visit per Year

1460 N HALSTED ST STE 501
CHICAGO, IL 60642

1-800-HEADACH

1-800-432-3224

1-773-388-6390

Schedule An Appointment

*Diamond Headache Clinic’s goal is to rehabilitate, restore and improve function and independence, as well as to reduce the effects of the condition. Results may differ and no claims, promises or guarantees are being made or implied about the average, typical or expected results.