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?By including your email address, you are providing consent for Bond Eye Associates to send you marketing emails in the future.

example@example.com