Headache Form *** For each question, check all the boxes that apply to you (ie you may check more than 1 box)Did you suffer from headaches when you were younger?* As a child As a teenager In my 20’s – 40’s In my 50’s or 60’sWhen did your current headache problem begin?*Precipitating Event - Was there a precipitating event or trigger for your current headache problem?* None known Specific stress Injury Motor vehicle accident Illness Menarche (first period) Pregnancy Birth Control Pill Hormone Replacement OtherPlease ExplainFrequency of headaches - On average, how often do you have headaches? They occur __________ times each...**DayWeekMonthAre they increasing in frequency?*YesNohey are more frequent on:* Weekdays Weekends Spring Summer Fall WinterHeadaches typically begin:* Gradually Suddenly Varieshey usually begin in the:* Morning Afternoon Evening NightHow long before they reach maximal intensity?** Minutes HoursHeadaches usually last (with medication)**MinutesHoursDaysHeadaches usually last (without medication)**MinutesHoursDaysHow bad are your headaches? With medication* Mild Moderate Severe IncapacitatingHow bad are your headaches? Without medication* Mild Moderate Severe IncapacitatingHeadaches prevent activities* School Work Household choresWhere do you feel the pain during your headaches?* Left side Right side May be either side Both sides Forehead Temple Behind eye(s) Back of head Neck OtherPlease ExplainWhat does the headache pain feel like?* Pressure Stabbing Throbbing Tight band Burning Dull ache OtherPlease ExplainDo any of the following bring on/trigger your headaches?* Foods (specific food triggers will be discussed later in the questionnaire) Too much caffeine Not getting enough caffeine Hunger / Skipping meals Alcohol Wine Fatigue Too little sleep Too much sleep (sleeping in) During stressful times After stress (first day of vacation, weekend, after a test) Menstruation Exercise Sexual activity Coughing Prolonged computer work Weather changes Certain Odors Bright lights/sun Loud sounds OtherPlease ExplainDo you experience any of the following before your headache begins?* Mood changes Personality changes Change in appetite Food cravings Neck pain Fatigue No, I don’t experience any of these OtherPlease ExplainDo you ever experience any of these warning symptoms before your headache begins?* Bright lights / flashes of lights/ multi-colored lights (circle applicable description) Zig-zag lines Partial loss of vision / blurry vision / blindness (circle applicable) Numbness / tingling Paralysis Dizziness or vertigo Upset stomach / nausea No I don’t have theseDo you experience any of these symptoms during your headaches?* Nausea / upset stomach Vomiting Bright lights/sun bothers you Loud sounds bother you Strong smells/odors bother you Dizziness / lightheadedness / vertigo (circle applicable description) Numbness or tingling Increased sensitivity of Scalp / Hair / Ears Eye tears Runny or stuffy nose Difficulty concentrating Mood changes / irritabilityDuring a headache, what makes you feel the most comfortable?* Lying down / sleeping Being in a dark quiet room Keeping physically active Pacing back-and-forth Massage your head Tying something around your head Cold pack on your head/neck Hot pack on your head/neckDuring Milder headaches:* I am able to function normally My ability to function is slightly decreased My ability to function is severely decreased I am totally bedriddenDuring moderate or severe headaches:* I am able to function normally My ability to function is slightly decreased My ability to function is severely decreased I am totally bedriddenHow many times would you estimate that you have visited the following because of your headaches in the past 1 year?Family physicianWalk-in clinicEmergency departmentHow many days of work or school have you missed in the past 1 year because of headaches?*What diagnostic testing have you pursued for your headaches?* CAT Scan MRI EEG Sinus X-rays Neck X-rays OtherPlease ExplainPrevious Consultations-Have you seen any of the following about your headaches?* Neurologist ENT (Ears, Nose and Throat specialist) Dentist Psychiatrist Pain Clinic Eye Doctor Internal Medicine Allergy Specialist Chiropractor Acupuncturist Nutritionist Massage Therapist Naturopath (homeopath, herbalist) Psychologist Physical TherapyPlease current headache medication and list their efficacy (according to 1 to 5 level)Please list alternate, non-pharmaceutical treatments attempted: i.e. ice packs, essential oils, herbal products, etc.PhoneThis field is for validation purposes and should be left unchanged.
