Microsoft word - taylor headachequestionaire 2013

Headache Questionnaire
Patient Name:_________________________ Date Seen:____________________________
Please answer the following questions regarding your headaches:
A. Headache Onset

1) My headaches started _____ years ago at _____ years of age. 2) Any associated head injury? Yes/No 3) Loss of Consciousness? Yes/No 4) Any history of infection around your brain or spinal cord? Yes/No Comments:__________________________________________________________________
B. Current Headache Frequency

1) My headaches occurs ____ all the time ____ daily but not all the time ____times per week ____ times per 2) Has the frequency recently changed? Yes/No Comments:__________________________________________________________________
C. Headache Location (circle the most common locations)
D. Headache quality (circle any that apply)
Throbbing/Pulsating Pressure/Squeezing/Bandlike Stabbing/Sharp Dull/Nagging/Aching Comments:__________________________________________________________________
E. Headache Timing (circle any that apply)
My headaches tend to occur: when I wake up F. Headache Duration:

1) My headaches typically last _____ hours if treated. 2) My headaches typically last _____ hours if not treated. G. Headache Severity (circle the average pain and limitation of your headaches)
1) Average headache pain is: 1 2 3 4 5 6 7 8 9 10 out of 10 3) My headaches usually limit my activity as follows: 1 = they allow normal activity. 2 = they are disturbing and limit some normal activity, bed rest is not necessary. 3 = normal activity has to be discontinued, bed rest may be necessary. 4 = bed rest is necessary Comments:_______________________________________________________________
H. Associated Symptoms (circle any symptoms that occur before or during your headaches)
I. Do you have an aura before your headaches? (ie. Visual changes, numbness)
J. Precipitating Factors (circle the appropriate answer)
1) Do you have any problem falling asleep, staying asleep, or waking up often at night? Yes/No 2) Do you have a job or other stress? Yes/No 3) Do you find it difficult to relax? Yes/No 4) Do you feel anxious or depressed? Yes/No 5) Do any of the following trigger or worsen your headaches? Comments:__________________________________________________________________ 1) My headaches are worse around my periods? Yes/No 2) My headaches are worse during pregnancy? Yes/No Comments:__________________________________________________________________ K. Past Medications: (circle medications used for headaches in the past and reason for stopping)
Acute Pain Treatment
Helps Allergy/Adverse Reaction Doesn’t Help
Preventative Treatment
Helps Allergy/Adverse Reaction Doesn’t Help


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