Initial Consultation_Version2 - Daith Piercing 2020

Question Title

* 1. Please Fill In Your Details Below

First Name

Surname

Address

Address 2

City/Town

State/Province

Postal Code

Phone Number

Question Title

* 2. Email address

Question Title

* 3. Today's Date

Date / Time

Date

Question Title

* 4. What clinic is this today

Sussex - Burgess Hill

London - Harley Street

Home Visit

Other

Question Title

* 5. Are you Male or Female

Male

Female

Trans Gender

Question Title

* 6. Your age Please

15/20

20/30

30/40

40/50

50/60

60/70

Over 70

Other (please specify)

Question Title

* 7. What do you do for a living / during the day

Question Title

* 8. What best describes your symptoms - tick appropriate

Bilateral Migraine

Left Migraine

Right Migraine

Tension Headache

Cluster Headache

Head Fog

Constant Head Fog

Anxiety

Hyper Vigilance

Post Traumatic Stress Disorder PTSD

Obsessive-Compulsive Disorder OCD

Depression

Silent Migraine

Stomach Migraine

Irritable Bowel Syndrome IBS

Fibromyalgia only

Tremors

Neck Tension

Shoulder Tension

Vertigo

Nightmares

Flashbacks

Other (please specify)

Question Title

* 9. How was the initial stimulation test

Very Positive on Left & Right

Somewhat Positive on Left & Right

Not positive on Left & Right

Left only - Very Positive

Left only - Somewhat Positive

Right only - Very Positive

Right only - Somewhat Positive

No Reaction

Negative Left

Negative Right

Other (please specify)

Question Title

* 10. Is this consultation Migraine / Headache related

Yes