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| Marerro, LA
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Migraines: Pre-Screening Questionnaire
Name
*
Email Address
*
Phone
*
Are you between 18 and 65?
*
Select one...
Yes
No
Do you have more than 4 migraines per month?
*
Select one...
Yes
No
Do you have less than 15 headaches per month?
*
Select one...
Yes
No
Check any of the following that apply to you:
*
Diagnosis of Hypertension
Diagnosis of High Cholesterol
Diagnosis of Diabetes
Mother or Father has a Family History of Heart Disease
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