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:

How long ago did your headaches start?
Headaches started years ago.
At what age did your headaches start?
I was under 20 20-30 30-50 over 50 years old.

CAUSE:

Did you have any accident or injury that may have started your headaches?
Yes No
Do you feel that something else in your life may have started them?
Is it: menstruation emotional crisis medical illness

FREQUENCY:

How often do they occur?
They occur * times each day week month
* Please type digits, not words, in the box

LOCATION:

Where are they located?
left side right side either side all over head ("hatband") face / jaw
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:

When I have headaches I:

My headaches are worse if I:

Yes	No
		Drink alcohol
		Cough, sneeze or move my bowels
		Run or exercise

DURATION:

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.
Have you ever been free of headaches? Yes No

PRECIPITATNG FACTORS:

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:

**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:

Are your headaches more frequent in the (check all that apply):
spring summer fall winter

PRODROME/AURA:

Do you have any warnings/symptoms of headache for a period of time greater than 1 hour before the headache begins?
Yes No

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:

How would you describe your usual headache (check all that apply)?

Pain is:	Throbbing	Dull	Sharp
	Tight band	Stabbing	Burning

SEVERITY:

Please check the item that best describes the severity of your headache pain.
The Pain is:

Mild

Moderate

Severe

Intolerable

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:

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:

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:

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

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):

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

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:

Do you get any other types of headaches? (Please check all that apply)
Tension headache Sinus headache Cluster headache Emotional based headache

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:

Would you say your general health is: Excellent Good Poor

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

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

Are you allergic to any medicines?

Medication	Allergic reaction	Date

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

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

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

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:

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:

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:

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:

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..........................................	</

Headache History Questionnaire

HEADACHE HISTORY

GENERAL HISTORY

DAILY LIVING PROFILE