Headache Questionnaire

Name:
Date of Birth:
Phone Number:
Email Address (Optional):
Are you experiencing a headache that has lasted for 12 weeks or more?:
On a scale from 0 - 10, how severe is your headache?:
In the past month, how often did you have a headache?:
Does your headache prevent you from completing day to day activities?:
My quality of life has been significantly impacted by the headaches I experience:
Have you spoken to your primary care doctor about your headaches?:
Are you currently being treated for your headaches?:
Any Additional Information:

Ohio County Healthcare

Ohio County Healthcare is a non-profit Joint Commissioned accredited health system which provides a wide range of hospital, primary care and specialty physician services.

Contact Us Careers

What type of care do you seek?

Ohio County Healthcare offers a broad range of healthcare across a diverse landscape.

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