Emergency Treatment Information Form: Patient

Emergency 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

Other Medications: __________________________________________________________________________

___________________________________________________________________________________________________

Allergies: ________________________________________________________________________________________

___________________________________________________________________________________________________

_________________________________________________ _____________________ Signature Date

This form provided by About Headaches/Migraine © Teri Robert, Ph.D., About, Inc., 2001, 2002	http://headaches.about.com headaches.guide@about.com