7#pp))))) 3 ===== ]]]f]8 Emergency Treatment Information: I am experiencing extreme head pain resulting from a Cluster Headache attack. I am not a "drug seeker," and have brought a form from my doctor verifying my diagnosis and treatment information. Registration Information: ________________________________________________________________________________ Full Name ________________________________________________________________________________ Address City State Zip Code _____________________________________ _____________________________________ Home Phone Office Phone ________________________________________________________________________________ Employer ________________________________________________________________________________ Emergency Contact Relationship Phone Number Treatment Information: On a scale of 1 - 10, I currently rate my pain at ________. To treat this Cluster Headache attack, I have taken these medications: ________________________________________________________________________________ Medication Dosage Time Taken ________________________________________________________________________________ Medication Dosage Time Taken ________________________________________________________________________________ Medication Dosage Time Taken Other Medications: ________________________________________________________________________________ Medication Dosage Condition ________________________________________________________________________________ Medication Dosage Condition ________________________________________________________________________________ Medication Dosage Condition ________________________________________________________________________________ Medication Dosage Condition ________________________________________________________________________________ Medication Dosage Condition Known Allergies: ________________________________________________________________ ________________________________________________________________________________ _____________________________________________________ _______________________ Signature Date This form provided by About Headaches/Migraine http://headaches.about.com 2001, 2002 Teri Robert, About, Inc. headaches.guide@about.com h!NXQ ^gHXoE' p Q 2 #Up$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$%!NXQ ^gHXopE' p Q 2 fU0p ''@xxxxxxxxxxxxxx2 ppp p =/B8 Emergency Treatment Information:Theresa M. RobertTimes New Roman$Verdana%Times New Roman CE&Times New Roman Cyr(Times New Roman Greek)Times New Roman Tur*Times New Roman (Hebrew)+Times New Roman (Arabic),Times New Roman Baltic-Times New Roman (Vietnamese) Verdana CE Verdana Cyr Verdana Greek Verdana TurVerdana BalticVerdana (Vietnamese)pp