On which side does your head hurt?
LeftRightComplete
How frequently does your head hurt?
DailyOnce a weekOnce a MonthLess Than Once a Month
Do you feel nauseous or vomit when you get an attack?
YesNo
Is your vision blurred when you get an attack?
Late nightsTensionBeing out in the sunBad tummy
For the women- When do you do you get an attack?
Before periodsDuring PeriodsAfter periods
Are you already a patient with Dr. Manoj's Homeopathy? If yes then please state your Registration number in the ‘more symptoms’ column at the end of the questionnaire.
Name:
Email Address:
Contact Number:
Location/City:
Gender:MaleFemale
Age:-Select-1 Month2 Months3 Months4 Months5 Months6 Months7 Months8 Months9 Months10 Months11 Months12 Months234567891011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859606162636465666768697071727374757677787980818283848586878889909192939495969798
More Symptoms:
