HEADACHE QUESTIONNAIRE

HEADACHE QUESTIONNAIRE

Patient Name: __________________________________________________

Patient Address: ________________________________________________

Patient Date of Birth: ____________________

1. Do you have more than one type of headache? ____Yes ____No

2. Headaches started ______ years ago.

Your age at the time: ____under 20 ____20-30 ____30-50 ____over 50

3. Frequency: They occur _______ times each: ____day ____week ____month

Are they increasing? ____Yes ____No

Are they more frequent: ___weekdays ___weekends ___vacation ___no relation

4. Onset of headache: ____gradual ____sudden ____morning ____afternoon ___night

5. Duration: with medication, lasts________ ___hours ___days

without medication, lasts ________ ___hours ___days

6. Free of headache from ________________ to ________________ ___never free

7. Intensity: with medication___mild ___moderate ___severe ___incapacitating

without medication ___mild ___moderate ___severe ___incapacitating

Headaches prevent daily activities such as work or school: ___Yes ___No

8. Headaches effect on ability to function:

____function normally

____function slightly decreased

____totally bedridden

____function severely decreased

9. Location: ___left side ___right side ___either side ___both sides ___neck/back of head

___behind eye(s) ___other:_____________________________________

10. Pain Type: ___throbbing ___achy ___pressure ___stabbing ___shooting ___dull

___tight ___burning ___searing ___other:________________________

11. Hormonal: Are your headaches affected by ___pregnancy ___your menstrual cycle

12. Caffeine use: _____cups of coffee per day ______soft drinks per day

13. Sleep: You usually get __hours per night. You feel rested the next day: __Yes __No

14. Headaches can be brought on by:

___high altitudes___weather changes___foods___lack of sleep

___too much sleep___medications___odors___sex/orgasm

___physical exertion___menstruation___hunger___stress

___loud sounds___bright light/sun___alcohol___fatigue

___other:________________________________________________________________

15. Headache warning signs:

___lightheadedness___weakness___light flashes

___numbness___upset stomach___dizziness

___zig-zag lines___blindness___other:_________________________

16. Associated Symptoms:

___nausea/vomiting___increased appetite___insomnia

___constipation___decreased appetite___sensitivity to:

__light

__odors

__sounds

___fatigue/weakness___ringing in ears___one eye tears

___both eyes tear___lightheadedness/dizzy___sore/stiff neck

___blurred/double vision___numbness/tingling___poor concentration

___anxiety/tension___change in sexual interest___memory problems

___runny/stuffy nose___increased urination

___other:________________________________________________________________

17. During a headache, you are more comfortable:

___hot or cold compress___keeping active___pacing

___massage/pressure on scalp___dark quiet room___lying down

___other:________________________________________________________________

18. Previous evaluations and tests:

___neurologist_____________________________headache specialist ______________________

___internist_______________________________ear, nose, throat specialist _________________

___eye exam______________________________dental evaluation ________________________

___MRI__________________________________spinal tap______________________________

___EEG__________________________________sinus x-rays_____________________________

___CT scan_______________________________cervical spine films_______________________

___angiogram_____________________________other____________________________________

Current Medications

Please list ALL medications currently taken, including over-the-counter medications and vitamins.

MedicationDaily DosageResults

Side EffectsMedicationDaily DosageResults

Side Effects

1.7.

2.8.

3.9.

4.10.

5.11.

6.12.

Previous Headache Medications

MedicationDaily DosageResults

Side EffectsMedicationDaily DosageResults

Side Effects

1.10.

2.11.

3.12.

4.13.

5.14.

6.15.

7.16.

8.17.

9.18.

Please circle the medications you have taken for your headaches.

AdapinDecadronInderalNortriptylineStelazine

AdvilDemerolIndocinOrudisSumatriptan

AleveDepakoteLidocaineOxygenTalwin

AmergeDesyrelLithiumPamelorTegretol

AmitriptylineDHE-45LodineParafon ForteTenormin

AnafranilDilantinLorcetParnateThorazine

AnaproxDolobidLortabPaxil Topamax

AnsaidDoxepinLudiomilPercocet Toradol

ArthrotecEffexorMaxaltPercodanTriavil

AscendinElavilMaxalt MLTPercogesicTylenol

AspirinEletriptan MedrolPeriactinTylenol/Codeine

AtivanEquagesicMellarilPhenerganUltracet

AventylErgomarMetherginePrednisoneUltram

AxertErgotamineMethysegideProcardiaValium

BextraEsgicMidolProlixinValproic Acid

ButorphanolExcedrineMidrinPropanololVerapamil

CafergotExcedrine MigraineMigranalProzacVicodin

CalcimarFeldeneMorphineReglanVioprofen

CardizemFioricetMobicRelafenVioxx

CarisoprodolFiorinalMotrinRelpaxVistaril

CelebrexFlexerilNadololRemeronVivactil

CliniorilFrovaNaprelanRizatriptanVoltaren

ClonidineFrovatriptanNaprosynSansertWellbutrin

CodeineHaldolNaproxenSeraxWigraine

CompazineHistamineNaratriptanSerzoneWygesic

CorgardIbuprofenNardilSinequanXanax

CyclobenzaprineImpipramineNavaneSkelaxinZoloft

DarvocetImitrex InjectionNeurontinSolumedrolZomig

DarvonImitrex NSNifedipineSomaZomig ZMT

DayproImitrex tabletNorpramineStadolOther__________