Melbourne Headache Neck and Jaw Questionnaire

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Find out if Melbourne Headache Neck and Jaw Clinic is the right place for you.
We will call you back to discuss your results.

Medical Disclaimer: this is intended to be for informational purposes only. It helps us identify if we may be help to help you. If you have had a new onset of severe headache, a change in your regular headache, or are experiencing any dizziness, numbness, tingling, slurring of words, drooping of face (that isn't your normal symptoms) please call your doctor.

Name *

Email Address *

Phone Number *

What type of condition do you suffer from? *

Headache

Migraine

TMJ pain

Neck pain

How long have you suffered this condition? *

Less than 3 months

3 - 6 months

6 - 12 months

1 - 2 years

2 - 5 years

5+ years

Is your condition worsening, improving, or stable? *

Worsening

Improving

Stable

Have you tried treatment before? *

Yes

If yes, what have you tried?

What impact is your pain having on your life? (0 no 10 severe) *

1-2

3-4

5-6

7-8

9-10

Do you suffer any of the following? *

Neck pain

Back pain

Depression/Anxiety

Tiredness

Stress

Required

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