Consultation form for VNS via a Daith Piercing 1. Question Title * 1. Please Fill In Your Details Below Name Address Address 2 City/Town ZIP/Postal Code Phone Number OK Question Title * 2. Email address Email Address OK Question Title * 3. Today's Date Date / Time Date OK Question Title * 4. What best describes your symptoms - Tick appropriate Migraine Tension Headache Cluster Headace 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 Skip as it not headache-related Other (please specify) OK Question Title * 5. Where are we today Burgess Hill Sussex Harley Street london OK Question Title * 6. Are you Male or Female Male Female Trans Gender OK Question Title * 7. How old are you OK Question Title * 8. What do you do for a living / during the day OK Question Title * 9. How was the acupuncture needle test needle 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) OK Question Title * 10. How often do you get migraines More than 10 a month More than 6 a month More than 4 a month Twice a month Once a month Occasionally I don't get migraines OK Question Title * 11. Do you get an aura with your migraine Yes No Somtimes I also get blurred or impaired vision I also get spots in my vision I also get a feeling of neausea I am also often physically sick It effects my speech Other (please specify) OK Question Title * 12. Do any direct family members suffer from migraines Mother Father Mother and Father Sisters or brother Grandparents No Other (please specify) OK Question Title * 13. How long does a headache last less than an hour Less than 3 hours Less than 6 hours Less than 12 hours All day Constant I don't get headaches OK Question Title * 14. How long does a Migraine last without taking any medication Less than an hour Less than 3 hours Less than 6 hours Less than 12 hours Around a day Around 2 days Around 3 days I don't get migraines Other (please specify) OK Question Title * 15. How long have you been having these migraines/headaches Around 1 year Around 2 years Around 4 years 4-7 years 7-10 years 10-15 years 15-20 years 20-30 years More that 30 years OK Question Title * 16. How often do you get headaches Continuous Every day Up to 5 a week Up to 3 a week Up to one a week Less than one a week I don't get headaches OK Question Title * 17. Do you get pins and needles or numbness in hands arms or feet In left hand In right hand In left arm In right arm In both hands In both arms In left foot/leg In right foot/leg No Other area of body Other (please specify) OK Question Title * 18. Do you have neck tension No Left side Right side Both sides Only occasionally Other Other (please specify) OK Question Title * 19. What Medication are you on at present Just Painkillers Just Triptans Triptans & Painkillers Nothing Injectable Erenumab Fremanezumab Other (please specify) OK Question Title * 20. What type of migraine do you have - has it been diagnosed. Migraine without Aura - Common Migraine Migraine with Aura - Classic Migraine with typical Aura without headache - visual problems, nausea, constipation but no head pain Basilar - Migraine with brain stem aura - teenage girls menstrual cycle partial or loss of vision Hemiplegic - Migraine vertigo and temporary paralysis - can rum in the family FHM Retinal - rare migraine with visual loss in one eye - Chronic migraine - 15 or more days of a month for more than 3 months Cluster Headache - one sided normally over one eye temple or forehead - normally wakes up with it Other (please specify) OK Question Title * 21. What Triptans are you on Right Now Imitrex (Sumatriptan) Zomig (Zolmitriptan) Maxalt (Rizatriptan) Relpax (Eletriptan) Treximet (Sumatriptan and Naproxen Sodium Tablets) Amerge (Naratriptan) Frova (Frovatriptan) Axert (Almotriptan) Sumavel DosePro (sumatriptan) Zecuity (sumatriptan iontophoretic transdermal system) Other (please specify) OK Question Title * 22. What alternative therapies have you tried - multiple answers allowed Acupuncture Physiotheraphy Massage Osteopathy Cranial osteopathy Nutritionist Cutting out foods Nerve Block Botox VNS Therapy Counselling Chiropractor Other (please specify) OK Question Title * 23. Have you had and of the below Nurologist CT Scan X-ray Private consultant Private medical help Been hospitalised for symptoms NHS Specialist No Other (please specify) OK Question Title * 24. Where does a full blown migraine stem from Behind the left eye Behind the right eye Left Temple Right Temple Left side of head Right side of head Left back of head Right back of head Central forehead None of the above Other (please specify) OK Question Title * 25. Have you ever had an accident with a whiplash injury ? Yes this was just before my headaches/migraines started Yes this was after my headaches/migraines started Yes this was well before my headaches/migraines started No never Other (please specify) OK Question Title * 26. Do you participate in any high impact exercise or activity No Never Running Jogging Contact sport Group competition such as football, hockey or rugby High impact exercise class Other (please specify) OK Question Title * 27. Have you ever had problems with neck or shoulder tension Yes No Unsure Other (please specify) OK Question Title * 28. What triggers do you think start your migraines/headaches off Hormones Weather Smells Dehydration Lack of sleep Bright lights Food stuffs Alchohol Coffee Stress Exersise Artifical light Computer screens Other (please specify) OK Question Title * 29. How was the Neck Compression Test Somewhat positive Positive Very positive No response Somewhat Negative Negative Very Negative Other (please specify) OK Question Title * 30. Is there a problem with your cervical vertebra C1 Atlas C2 Axis C3 C4 C5 C6 C7 T1 - T2 T3 - T4 T5 - T6 T7 - T8 T8 - T9 T9 - T10 T10 - T11 T12 - L1 L2 - L3 L4 - L5 Skip Other (please specify) OK Question Title * 31. Are you happy to participate in 3 surveys per year lasting around 5/10 mins sent by email Yes No OK Question Title * 32. Are you happy to be sent occasional promotional Emails Yes No OK Question Title * 33. What was the initial reaction from the piercing ? Shoulder relief Neck tension relief Improved eye sight or less eye strain Headache went Migraine went Headache worse Migraine worse New range of movement in neck Jaw release Euphoric Lifting sensation Negative reaction No reaction Felt sick Felt faint Slight lifting of headache Slight lifting of migraine Other (please specify) OK Question Title * 34. Spine Notes to be emailed to customer OK Question Title * 35. What side was pierced today Left Right Both None OK Question Title * 36. What Jewellery was used CBB BCR BMG Jewellery Other Jewellery OK Question Title * 37. Recommendations to be emailed to customer OK Question Title * 38. Observations to be noted for file OK DONE