How often do you experience Migraines?
Daily
2-3 times a week
Once a week
A few times a month
Rarely
How long do your Migraine attacks typically last ?
Less than 4 hours
4-8 hours
8-24 hours
More than 24 hours
At what age did your Migraine first begin?
Under 12 years old
12 - 18 years old
18 - 30 years old
Over 30 years old
Do you experience any warning signs (Aura) before the Migraine begins?
Yes
No
What symptoms accompany your MIgraines? (check all that apply)
Nausea or Vomiting
Sensitvity to light
Sensitivity to sound
Vison changes (blurred visio, flashing lights,etc)
Dizziness or Vertigo
Neck pain or tension
Other....
Have you identified any specific triggers for your Migraines? (check that apply)
Stress or emotional tension
Certain foods or drinks (chocolate, cafeine, alcohol,dairy)
Weather changes (humidity,barometric pressure)
Hormonal changes (menstrual cycle,pregnancy)
Strong smells or bright lights
Sleep irregularities (to much, or too little sleep)
Physical exertion or exercise
Skipping meals or fasting
I do not know my triggers
Other....
Have you ever followed a special diet (e.g. Keto, Paleo,low-Lectin)to manage your Migraines?
Yes, and it helped
Yes, it did not help
No, i haven't tried any diets
I'm unsure about dietary changes
Do you experience any digestive issues alonside your migraines? (check all that apply)
Bloating
Gas
Diarrhea
Constipation
Acid reflux or Constipation
Food intolerance or sensitivities
None of the above
Have you ever been diagnosed with a Leaky-Gut or Irritable bowel syndrom (IBS)
Yes
No
I suspect i might have it, but I haven't been diagnosed
Have you ever taken Antibiotics or anti inflammatory drugs (NSAIDS) frequently in the past ?
Yes
No
What methods have you tried to manage or prevent your Migraines? (check all tat apply)
Prescription medication (Triptans,pain killers)
Over-the-counter pain relief (Ibuprofen, Aspirin)
Supplements (Magnesium, Riboflavin, coQ10)
Stress reduction techniques (yoga, Meditation, Therapy)
Special diets (Gluten-free, Keto, Low-Lectin)
Time restricted feeding or Intermittent fasting
Acupuncture, Chiropractic treatments
None of the above
Do you take any prescription medication for your Migraines or other health conditions?
Yes, (please list the medications....)
No
How willing are you to make dietary changes to reduce your Migraines?
Very willing
Somewhat willing
Reluctant, but open to trying
Not willing
How committed are you to track your food,, symptoms and triggers to identify paterns?
Very commited
I could try it, but I'm not sure I can be consistent
I prefer not to track
Have you ever been diagnosed with any other chronic conditions ? (check all that apply)
High blood pressure
Diabetes
Autoimmune disease (hashimotos, Rheumathoid Arthritis)
Hormonal Imbalances (PCOS, thyroid issues)
None of the above
Do you have a family history of Migraines
Yes
No
Not sure
On a scale of 1 to 10, how much do your Migraines affect your daily life ?
1
2
3
4
5
6
7
8
9
10
Is this an important enough priority that you can allocate (or find) the financial resources towards a solution?
Yes
No
Phone
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Full Name
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Thank your filling out the Survey. We will contact you when you are a good fit for the Migraine Solution Coaching program.