MigraineAndHeadache

MigraineAndHeadache.com and JTV Energy Lights
@Teplitz Enterprises, Inc. Since 1974 Date:________________________

MIGRAINES AND HEADACHES Do you have a headache?

Yes

No

Yes

No

9 A.M.

12 P.M.

3 P.M.

5 P.M.

FATIGUE On a scale of 1 to 10, rate your level of fatigue:
	No Fatigue		Low		Moderate			High		Very High

	1	2	3	4	5	6	7	8	9	10
9 A.M.
12 P.M.
3 P.M.
5 P.M.

PRODUCTIVITY On a scale of 1 to 10, rate your level of productivity:
	Very Low		Low		Moderate			High		Very High

	1	2	3	4	5	6	7	8	9	10
9 A.M.
12 P.M.
3 P.M.
5 P.M.

ATTITUDE On a scale of 1 to 10, rate your attitude:
Very Negative		Low		Moderate		High		Very Positive

	1	2	3	4	5	6	7	8	9	10
9 A.M.
12 P.M.
3 P.M.
5 P.M.

GLARE On a scale of 1 to 10, rate your level of eye strain due to glare:
Very Low		Low		Moderate		High		Very High

	1	2	3	4	5	6	7	8	9	10
9 A.M.
12 P.M.
3 P.M.
5 P.M.

ANXIETY On a scale of 1 to 10, rate your level of anxiety:
Very Low		Low		Moderate		High		Very High

	1	2	3	4	5	6	7	8	9	10
9 A.M.
12 P.M.
3 P.M.
5 P.M.