7#  ))))) 3 ===== ]]]]8Emergency Treatment Information: I am experiencing extreme head pain resulting from a migraine 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 migraine attack, I have taken these medications: _________________________________________________________________________ Medication Dosage Time Taken _________________________________________________________________________ Medication Dosage Time Taken _________________________________________________________________________ Medication Dosage Time Taken _________________________________________________ _____________________ Signature Date This form provided by About Headaches/Migraine http://headaches.about.com 2001 Teri Robert, About, Inc. headaches.guide@about.com h!AK~,wN_v> v  !"AKL~,-wNO_vw> v      $@3     =/B8 Emergency Treatment Information:Theresa M. Robert Times New RomanVerdanaTimes New Roman CETimes New Roman CyrTimes New Roman GreekTimes New Roman TurTimes New Roman Balticq Verdana CEr Verdana Cyrt Verdana Greeku Verdana TurvVerdana Baltic