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Dear patient: thank you for taking the time to carefully fill out this paperwork

1. When you have headaches, how often is the pain severe? 2. How often do headaches limit your ability to do usual daily activities including household work, 3. When you have a headache, how often do you wish you could lie down? 4. In the past 4 weeks, how often have you felt too tired to do work or daily activities because of 5. In the past 4 weeks, how often have you felt fed up or irritated because of your headaches? 6. In the past 4 weeks, how often did headaches limit your ability to concentrate on work or daily 7. At what age do you remember your first significant headache? _____________________ 8. When was the last day you were headache free? 9. When was the last time you had 6 headache-free days in a row? ____________________ 10. How often do you have to go to the Emergency Room for headaches? _____________________ 11. When your headaches first started, do you remember getting some relief by changing positions 12. What other physicians have you seen for headaches/facial pain? _____________________________________________________________________________ 13. Have you ever been admitted to the hospital for your headaches? ________________________ 14. Have you tried chiropractic care or acupuncture for your headaches? Yes or No 15. What studies have you had for your headaches? a. MRI of head: Y/N Approximate date and place of procedure:____________________ b. CT scan of head: Y/N Approximate date and place of procedure:__________________ c. MRI of neck: Y/N Approximate date and place of procedure:____________________ d. Spinal Tap: Y/N Approximate date and place of procedure:_____________________ 17. Do you clench or grind your teeth at night? 19. Do you clench or grind your teeth at night? 20. Have you been diagnosed with TMJ disorder? 21. Does your neck hurt during the headaches? 22. Does your neck hurt when you don’t have a headache? Y or N Circle any of the medicines below that you tried before to stop headaches once they start: Imitrex tablets Other medicines used to stop headaches: ______________________________________________________________________ Circle all of the medicines below you have used for prevention of headaches/facial pain: Gabapentin Other medicines used for headache prevention: ______________________________________________________________________
How many types of headaches do you have?_________
Fill out the information on
this page and the following pages for each type of headache you have.
Headache #1
1. Mark the areas where your head hurts for this headache type: 2. Have you had this headache type for less than 3 months? Y or N 3. How would you describe the pain? (examples: throbbing, squeezing, dull, ________________________________________________________________ 4. Do you have nausea with this headache? 5. Do you have sensitivity to light with this headache? 6. Do you have sensitivity to sound with this headache? 7. Do you have sensitivity to smell with this headache? 8. Do you have changes in your vision before or during this headache? Y or N 9. Has this headache changed recently? Y or N If so, How has it changed?________________________________________________________ 10. What time of day are these headaches the worst? ________________________ 11. What medicines have helped this headache? ________________________________________________________________ 12. Circle any of the aggravating factors below: Aspartame Chocolate Strenuous Monosodium Headache #2 (If you only have 1 type of headache, you are finished)
13. Mark the areas where your head hurts for this headache type: 14. Have you had this headache type for less than 3 months? Y or N 15. How would you describe the pain? (examples: throbbing, squeezing, dull, ________________________________________________________________ 16. Do you have nausea with this headache? 17. Do you have sensitivity to light with this headache? 18. Do you have sensitivity to sound with this headache? 19. Do you have sensitivity to smell with this headache? 20. Do you have changes in your vision before or during this headache? Y or N 21. Has this headache changed recently? Y or N If so, How has it changed?________________________________________________________ 22. What time of day are these headaches the worst? ________________________ 23. What medicines have helped this headache? ________________________________________________________________ 24. Circle any of the aggravating factors below: Aspartame Chocolate Strenuous Monosodium

Source: http://www.norleaneuro.com/HTML/Headache/nlgh_headache_questionnaire.pdf

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