Bond Eye Associates - Headache Evaluation

1

How bad is your headache pain?* This field is required.

Severe painModerate pain

2

Is the pain on only one side of your head?* This field is required.

YESNO

3

Is the pain on both sides of your head?* This field is required.

YESNO

4

Did you recently experience a head injury? * This field is required.

YESNO

5

Do you have PMS? * This field is required.

YESNO

6

Do you have a cold, the flu, a sinus infection or a hangover?* This field is required.

YESNO

7

Are you experiencing pulsing or throbbing pain?* This field is required.

YESNO

8

Are you experiencing pressure or a squeezing sensation?* This field is required.

YESNO

9

Is your headache brief (under 2 hours) and are you experiencing a sharp or stabbing pain in one eye or feeling restless?* This field is required.

YESNO

10

Is your headache long lasting (over 4 hours) and are you experiencing sensitivity to light and sound or experiencing nausea or vomiting?* This field is required.

YESNO

11

What is your name?* This field is required.

First Name

Last Name

12

What is your phone number?* This field is required.

Area Code

Phone Number

13

What is your email address?* This field is required.By including your email address, you are providing consent for Bond Eye Associates to send you marketing emails in the future.

example@example.com