Microsoft word - headache questionnaire.dot
The Woodlands Neurology & Sleep
9303 Pinecroft Dr, Ste 270
The Woodlands, TX 77380
Have you ever suffered a head injury which resulted in a loss of consciousness? If sodescribe the date, circumstances, amount of time you were unconscious, any medical care youreceived as well as any medical symptoms which resulted from the injury.
Have you ever had a brain infections such as meningitis or encephalitis? If so, please providedetails including your age, symptoms, specific diagnosis and any hospitalization or treatmentyou received.
How old were you when you first suffered from headaches? (Do your best to recall, even ifthose headaches were different from your current headaches.)
When did the type of headache you are now suffering from begin? _______________________
How often are you experiencing the headaches (number of days per week you haveheadaches, i.e. 4 days per week)?__________________________________________________
How long do the headaches last if untreated or unsuccessfully treated (list a range of time inhours or days, i.e. 4-72 hours)? ___________________________________________________
Since your current headache began, what is the longest period of time you have goneWITHOUT a headache? _________________________________________________________
How many days of work or school have you missed because of headaches? ________________
How many days do you feel you have been impaired at work or school because of yourheadaches?__________________________________________________________________
How many times have you been to an acute care clinic for your headaches? ________________
How many times have you been to an Emergency Room for your headaches?_______________
List any other care providers you have seen for headaches (Chiropractors, Psychologists,etc.). ________________________________________________________________________
Before you headaches begin, do you get any kind of warning (symptoms can includedisturbances of vision, abnormal sensations, loss of strength)? If you do, please describe thesymptoms including their duration, progression and relationship to headaches (i.e. I gettingling in my left hand 20 minutes before my headache that goes away after 30 minutes).
When your headache begins, how long does it take before it is at its most severe (be asspecific as possible, i.e. over 20 to 30 minutes)? ______________________________________
Describe the location of your headache (if it begins in one area and spreads, describe it).
Are your headaches worse on one side of your head; if so, which side? ____________________
Which of these terms best describes the severity of your headache: Mild, moderate or severe? _
Please rate your headache on a scale of 0 to 10 under the following conditions:Lying down
Along with your headache, please check any other symptoms you experience, even if you donot experience these symptoms on every occasion____Sensitivity to light
Are you more likely to get a headache if your stress level is increased? ____________________
Have you found that any particular food seem to bring on a headache? If so please list thosefoods. _______________________________________________________________________
Have you found that anything in the environment triggers headaches (i.e. smoke, fumes etc.)? _
For females, do you seem more likely to get headaches around the time of your menstrualperiod, or at any other time in your cycle?___________________________________________
Along with your headaches have you ever experienced the following____tearing from one eye
Do your headaches tend to occur at the same time each day or night? If so, when? __________
Do your headaches tend to occur in clusters where you experience almost daily headaches forweeks to months followed by month long periods without headaches? ____________________
If you suffer from these kinds of headaches, have you ever experienced one of theseheadaches shortly after a drink of alcohol? __________________________________________
Are your headaches improved if you are able to sleep?_________________________________
What other activities, aside from medication, seem to help your headaches? ________________
Have you ever been prescribed a medication for headaches which you took every
day whether you had a headache or not? If so, please list the medication, the
Inderal (propranolol)Elavil (amitriptyline)
dose, the amount of time you took it, how well it worked and any problems you
Please list any medications you have taken in the past for headaches, how the medicine
worked as well as any problems you had with the medication (i.e. Aspirin helped mild
headaches but caused an upset stomach):______________________________________ ibuprofen
______________________________________________________________________ Midrin______________________________________________________________________ Fiorinal______________________________________________________________________ Fioricet
______________________________________________________________________ Naprosyn______________________________________________________________________ Excedrin
Have you ever had been evaluated previously by a Neurologist for your headaches? If so,please list the Neurologist's name, location, date of evaluation, diagnosis and treatment. (Ifthis information is in your health record just indicate that.)
Have you ever had any diagnostic tests done for your headaches, such as CAT scans orMRIs? If so, list the study, date and result if known. If performed at Memorial Hermann,please inform the front desk of the study and date.
Do any of your blood relatives get headaches? If so, who and what type of headaches?
As Neurologists, it is important we understand your concerns. Keeping this in mind, pleaseanswer the following questions to the best of your ability.
What kind of headaches do you feel you suffer from?__________________________________What do you feel is the cause of these headaches? ____________________________________
What kinds of tests do you feel are the best for making a diagnosis of headache?____Medical history and
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