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Microsoft word - headache questionnaire.dot

The Woodlands Neurology & Sleep
9303 Pinecroft Dr, Ste 270
The Woodlands, TX 77380
Office 281-465-4050
Fax 281-465-4105
HEADACHE DATABASE
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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