Headache History Questionnaire

 

HEADACHE HISTORY
First Name: Last Name:
Email: * Required
City:  
State:
Province: (Non US)
Country:
Age: * Please type digits, not words, in the box

BEGAN:
  1. How long ago did your headaches start?
    Headaches started     years ago.
  2. At what age did your headaches start?
    I was under 20 20-30 30-50 over 50 years old.
CAUSE:
  1. Did you have any accident or injury that may have started your headaches?
    Yes No
  2. Do you feel that something else in your life may have started them?
    Is it: menstruation   emotional crisis   medical illness
FREQUENCY:
  1. How often do they occur?
    They occur * times each day week month
    * Please type digits, not words, in the box
     
LOCATION:
  1. Where are they located?
    left side right side either side all over head ("hatband") face / jaw
  2. Do they usually stay in one place or do they move around?
    usually stays in one place sometimes moves around often moves around.
PINPOINTING FACTORS THAT INFLUENCE MY HEADACHES:
  1. When I have headaches I:
    Yes No
    Have trouble falling asleep
    Wake up and stay awake for awhile
    Bright lights bother me
    Loud sounds bother me
    Have ringing in my ears
    One eye tears
    Both eyes tear
    Certain odors bother me
    My vision blurs
    Lose my appetite
    Have nausea
    Have vomiting
    Have a runny or stuffed-up nose
    Have flushing on one side of face
    Feel light-headed or dizzy
    My hands or feet tingle or feel numb
    Have a stiff or sore neck
    Prefer to be alone
    Can't go to work
    Must leave work early
    Feel tense and irritable

    My headaches are worse if I:
    Yes No  
    Drink alcohol
    Cough, sneeze or move my bowels
    Run or exercise
DURATION:
  1. Are your headaches continuous regardless of treatment?
    Yes No
    If not, how long do they usually last? (Answer all 3 parts of the question)
    Last hours if not treated.
    Last hours if treated immediately.
    Last hours if treated after they are severe.
  2. Have you ever been free of headaches?     Yes No
PRECIPITATNG FACTORS:
  1. My headaches are often brought on by:
    Fatigue Certain Foods Menstruation Washing Lying Down
    Stress/Tension Alcohol Coughing Chewing Stooping
    Oversleeping Certain Medications Shaving Talking  
HORMONAL:
  1. **WOMEN ONLY**
    1. Are your headaches affected by your menstrual cycle?
      Yes   No   Not Applicable
    2. Were your headaches affected by pregnancy?
      If yes, are they better   worse not applicable ?
SEASONAL:
  1. Are your headaches more frequent in the (check all that apply):
    spring summer fall winter
PRODROME/AURA:
  1. Do you have any warnings/symptoms of headache for a period of time greater than 1 hour before the headache begins?
    Yes No
  2. If you have any warning (lasting 1 hour or less) that a headache is coming, please indicate the warnings before a headache (check all that apply):
    Halos around lights Upset stomach Flashing lights Light headed
    Blind spot Feeling of tightness Dizziness  
PAIN TYPE:
  1. How would you describe your usual headache (check all that apply)?
    Pain is: Throbbing Dull Sharp
      Tight band Stabbing Burning
SEVERITY:
  1. Please check the item that best describes the severity of your headache pain.
    The Pain is:
    Mild
    Moderate
    Severe
    Intolerable

  2. Please check the statement that describes your activity level.
    I can continue with my normal activities  of the time  
    My normal activities are impaired and I am not as productive as usual  of the time  
    I must leave what I am doing and rest for a while   of the time  
    I am totally incapacitated and must go to bed  of the time  

FAMILY HISTORY:
  1. Please indicate if any blood relatives have severe headaches.
    Maternal - Mother's side: Mother aunt uncle grandparent cousin distant relative
    Paternal - Father's side: Father aunt uncle grandparent cousin distant relative   
EFFECTS OF HEADACHE:
  1. Since I've had headaches, I have
    Quit work.
    Seen a psychiatrist.
    Had marital difficulties.
    Feel life is worthless.
    None of the above.
PREVIOUS CARE:
  1. If a doctor has treated you before for your headaches, please provide the following:
    PHYSICIAN 1  
    Physician name
    City State
    Country
    Phone number
    FAX number
    PHYSICIAN 2  
    Physician name
    City State
    Country
    Phone number
    FAX number
TESTS/X-RAYS
    1. What tests and x-rays have you had relating to your headaches?
      MRI   Year (ex. 1999):
      CT   Year (ex. 1999):
      Spinal Tap   Year (ex. 1999):

    2. Abnormal blood tests:
      Abnormal results found with (check all that apply):
      blood count    chemistry tests    liver test    HIV    venereal disease

    3. Psychological testing:
      Did the results of testing indicate that you (check all that apply):
      did not have a psychological problem    were depressed    were suicidal
      were anxious    were manic    I don't know the test results
MEDICATIONS:
  1. What medications do you take or have you taken for your headaches?
    Ever Taken:
    Acute Medications (check all that apply):
    Sumatriptan (Imitrex) Naratriptan (Amerge) Rizatriptan (Maxalt)  
    Almotriptan (Axert) Zolmitriptan (Zomig) Frovatriptan (Frova)  
    Other Acute Medications (check all that apply):
    D.H.E Migranal Cafergot Wigraine
    Bellergal Midrin Fiorinal Vicoprofen
    Fioricet Vicodin Fiorinal w/ Codeine Esgic
    Fioricet w/ Codeine Phrenilin Phrenilin Forte Esgic Plus
    Tylenol w/ Codeine Darvocet N100 Naprosyn  
    Do you take any of the above medications three (3) or more days per week? Yes No
        
    Anti-Nausea Medications
    Metaclopramide Tigan Compazine Phenergan
    Do you take any of the above medications three (3) or more times per week? Yes No
       
    Rescue Medications
    Stadol Nasal Spray Ultram Morphine Demerol
    IV Compazine Toradol Halcion Restoril
    Prosom Ambien Dalmane  
    I use the above medication(s) times a
       
    Prophylactic or Daily Medications
    Amitriptyline (Elavil) Protriptyline (Vivactyl) Nortiptyline Doxepin
    SOMA Flexeril Inderal (Propranolol) Tenormin (Atenolol)
    Toprol Nadolol Timolol Cala (Verapamil)
    Ergonovine Maleate Clonidine Topamax Neurontin
    Depakote Serzone Prozac Zoloft
    Paxil Wellbutrin Atarax Ativan
    Buspar Effexor Librium Klonopin
    Xanax Valium Prednisone Lithium
    Meprobamate      
       
    Over the Counter Medications
    ASA, Anacin, Bufferin Ibuprofen (Advil, Motrin)
    Excedrin Acetaminophen (Tylenol)
    Naproxyn Sodium (Aleve)
    I use the above medication(s) times a
       
    Nutritional Supplements
    B Vitamins Magnesium    
     
    Herbal Supplements
    Feverfew
     
    Non-Medical/Alternative Treatments
    Biofeedback Massage Chiropractic Adjustment Yoga
    Acupuncture Acupressure Rolfing  
     
       
OTHER HEADACHES:
  1. Do you get any other types of headaches? (Please check all that apply)
    Tension headache    Sinus headache    Cluster headache    Emotional based headache

  2. My Previous Doctors
    Did not take my headaches seriously.
    Understood that they are a problem but did not wish to address them.
    Tried many medications with varying success.
    Tried many medications with no success and gave up.
    My case is too difficult for anyone to understand.

GENERAL HISTORY

 
HISTORY:
  1. Would you say your general health is: Excellent Good Poor

  2. Please check any of the following conditions you have had:
    Anemia Hearing problems
    Asthma Heart trouble
    Bronchitis High blood pressure
    Cancer/tumor Kidney/liver disease
    Diabetes Neuralgia/neuritis
    Epilepsy Nervous breakdown
    Eye problems Pneumonia
    Glaucoma Sinusitis
    Hay Fever Stomach/duodenal ulcer
    Head injury Tuberculosis

  3. Please list any medications you are now taking for conditions other than headache - prescription and non-prescriptions drugs.
    a. Medication:
      Start Date
      Dosage
      End Date
      Reason for Discontinuing
    b. Medication:
      Start Date
      Dosage
      End Date
      Reason for Discontinuing
    c. Medication:
      Start Date
      Dosage
      End Date
      Reason for Discontinuing
    d. Medication:
      Start Date
      Dosage
      End Date
      Reason for Discontinuing

  4. Are you allergic to any medicines?
    Medication Allergic reaction Date

  5. Are you allergic to any of the following foods?
    Cheese (any kind) Strawberries
    Cola drinks Other fruit
    Chocolate Nuts
    Eggs MSG (Mono-sodium Glutamate)(Accent)
    Milk Spicy foods

  6. Have you ever been hospitalized (including pregnancies)? Yes No
    If so, please indicate diagnosis...
    Date:
    Date:
    Date:

    Were you ever hospitalized due to your headaches? Yes No

  7. Do you smoke cigarettes?    Yes No
    If so...
    How many years have you smoked?
    How many packs a day?

  8. Please answer the following questions by checking each one that is true for you.
      Yes No
    Are you bothered a great deal by cold weather?...........
    Do your hands or arms ever tremble or shake?.............
    Ever short of breath after a little exercise?.................
    Ever awake at night short of breath?.........................

      Yes   No
    Do you ever consume alcoholic drinks?...................   
    If yes, how many drinks on an average
    Feel numb or weak on one side of your body?..........   
    Have you ever fainted?........................................   
    Have you ever had a convulsion?...........................   
    Is your eyesight getting worse?............................   
    Any problems with your ears or hearing?.................   
    Ever lost the ability to speak clearly?.....................   
    Ever had varicose veins in your legs?.....................   
    Ever had inflamed veins in your legs?......................   
    Do you exercise regularly?....................................   
    Ever use heroin, cocaine or similar drugs?................   

    WOMEN ONLY:
    How many pregnancies have you had?
    How many live births have you had?

 

DAILY LIVING PROFILE

 
NEIGHBORHOOD:
  1. Neighborhood concerns
    My neighborhood is too noisy...................................
    My neighborhood is too crowded..............................
    My neighborhood is too quiet...................................
    I do not have enough friends/neighbors.....................
    It is a dangerous neighborhood in which to live...........
    Having so many household tasks irritates me..............
    The weather here bothers me..................................
FAMILY:
  1. Family concerns
    I am recently married..............................................
    I am recently divorced or separated..........................
    I am alone too much at home...................................
    I am concerned about my relationship
    with my partner (husband/wife)................................
    I am concerned with my relationship with
    another family member (parent, child, brother, etc.).....
    I or one of my family is having legal problems..............
    There is serious illness in my family............................
    I am worried about one of my family members.............
    Someone in my family drinks too much.......................
WORK:
  1. Work concerns
    I am bored with the work I do...................................
    Other people make too many demands of me...............
    I am not satisfied with the work I do..........................
    I have too little control over my own work..................
    Often I feel overwhelmed by my responsibilities............
    There is never enough time to finish my work..............
PERSONAL:
  1. Personal concerns
    I worry about money a great deal.............................
    I feel lonely...........................................................
    I am bored with my life............................................
    I am generally concerned about my health..................
    I have particular concerns relating to my religion..........
    I think a lot about dying..........................................
    I just began a new job............................................
    I just lost my job...................................................
    I don't get along with my boss..................................
    I am having problems with people I work with..............
    I have difficulty falling asleep...................................
    I have difficulty staying asleep.................................
    I have difficulty staying awake.................................
    I feel tired when I wake up in the morning..................
    I feel nervous most of the time.................................
    I often feel depressed.............................................
    I worry a lot..........................................................
    I am ill frequently...................................................
    I have considered committing suicide.........................
    I have some sexual problems....................................
    I sometimes feel weak or light-headed.......................
    I often have pains in my shoulders, neck, or back........
    I often feel like crying.............................................
    I smoke too much..................................................
    I drink too much coffee...........................................
    I often drink too much alcohol..................................
    I eat more than I used to........................................
    I eat much less than I used to..................................
    I am concerned about my weight..............................
    I lose my temper more than I used to........................
   
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© Jerome Goldstein, MD, San Francisco Clinical Research Center. 2002