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* 1. Please Fill In Your Details Below

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* 2. Email address

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* 3. Today's Date

Date / Time

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* 4. Who is your consultation done by

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* 5. Who Is your piercing done by

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* 6. Are you Male or Female

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* 7. How old are you

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

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* 9. What is the reason you are here

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* 10. How often do you get migraines

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* 11. Do you get an aura with your migraine

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* 12. Do any direct family members suffer from migraines

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* 13. How long does a headache last

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* 14. How long does a Migraine last without taking any medication

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* 15. How long have you been having these migraines/headaches

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* 16. How often do you get headaches

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* 17. Do you get pins and needles or numbness in hands arms or feet

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* 18. Do you have neck tension

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* 19. What Medication are you on at present

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* 20. What type of migraine do you have - has it been diagnosed.

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* 21. What Triptans are you on Right Now

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* 22. What alternative therapies have you tried - multiple answers allowed

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* 23. Have you had and of the below

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* 24. Where does a full blown migraine stem from

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* 25. Have you ever had an accident with a whiplash injury ?

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* 26. Do you participate in any high impact exercise or activity

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* 27. Have you ever had problems with neck or shoulder tension

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* 28. What triggers do you think start your migraines/headaches off

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* 29. How was the Neck Compression Test

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* 30. Is there a problem with your cervical vertebra

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* 31. Are you happy to participate in 3 surveys per year lasting around 5/10 mins sent by email

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* 32. Are you happy to be sent occasional promotional Emails

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* 33. What was the initial reaction from the piercing ?

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* 34. Spine Notes to be emailed to customer

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* 35. What side was pierced today

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* 36. What Jewellery was used

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* 37. Recommendations to be emailed to  customer

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* 38. Observations to be noted for file

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