NEUROLOGY SCHEDULING
Headache Questions
Patient Name:
Required
Email:
Required
Not valid email address
Date of birth (mm/dd/yyyy):
Required
Please enter valid DOB
On what part of the head do the headaches start (check all that apply)?
Right Side
Left Side
Either Side
Back
On Top
Temples
Behind/Around Eye
Forehead
Face
Neck
Other
Required
After the headache starts - Does it usually:
Stay in one place
Move around
Required
Please explain:
How would you describe the pain (check all that apply)?
Throbbing/pulsating
Sharp
Pressing/squeezing
Dull/nagging
Stabbing
Other
Required
If other, please explain:
Describe the degree of pain on a scale of 1-10 (1=slight, 5=beginning to interfere with activity, 10=worst imaginable) for your
average
headache?
1
2
3
4
5
6
7
8
9
10
Required
Describe the degree of pain on a scale of 1-10 (1=slight, 5=beginning to interfere with activity, 10=worst imaginable) for your
worst
headache?
1
2
3
4
5
6
7
8
9
10
Required
Do your headaches interfere or prevent normal activities - work etc.?
Yes
No
Required
How long ago did the current headaches start?
Weeks
Months
Years
Required
How many?
Required
How old were you when any headache started?
Required
How long does the headache usually last?
Minutes
Hours
Days
Constant
Required
If minutes/hours/days, how many?
How often does the headache occur?
Day
Week
Month
Year
Constant
Required
If days/weeks/months/years, how many?
Does the headache awaken you from sleep?
Yes
No
Required
Is the headache getting...
Worse
Better
Fluctuating
No change
Required
DO ANY OF THE FOLLOWING SYMPTOMS OCCUR EITHER BEFORE,
DURING OR AFTER THE HEADACHE?
General (check all that apply):
None
Light sensitivity
Noise sensitivity
Odor sensitivity
Nausea/vomiting
Dizziness(lightheaded,spinning)
Fainting
Loss appetite
Cramps
Diarrhea
Slurred speech
Difficulty finding words
Difficulty understanding
Difficulty concentrating
Anxiety
Irritability
Fatigue
Skin sensitivity
Excessive yawning
Required
Face/Scalp (check all that apply):
None
Facial droop(right)
Facial droop(left)
Numbness(right)
Numbness(left)
Redness(right)
Redness(left)
Swelling(right)
Swelling(left)
Sweating(right)
Sweating(left)
Tenderness(right)
Tenderness(left)
Jaw pain(right)
Jaw pain(left)
Required
Neck (check all that apply):
None
Muscle tenderness(right)
Muscle tenderness(left)
Stiffness(right)
Stiffness(left)
Required
Hands and/or feet (check all that apply):
None
Cold(right)
Cold(left)
Pale(right)
Pale(left)
Sweaty(right)
Sweaty(left)
Required
Eyes (check all that apply):
None
Spots before eyes
Blurred vision(right)
Blurred vision(left)
Double vision
Can see only half of objects
Tearing(right)
Tearing(left)
Eyelid droop(right)
Eyelid droop(left)
Eye redness(right)
Eye redness(left)
Required
Arms/legs (check all that apply):
None
Arm numbness/tingling(right)
Arm numbness/tingling(left)
Leg numbness/tingling(right)
Leg numbness/tingling(left)
Required
Indicate if any of the following factors have brought or worsen your headache (check all that apply):
None
Head injury
Sleep too much/little
Emotional stress
Depression - anxiety
Physical activity
Erect position
Bending over
Straining - coughing
Sexual activity
Missed meal
Change in weather
Seasons
Alcohol
Processed meats
Chocolate
Citrus fruits
Cheeses
Missed meal
Other foods
Medications
Menstrual periods
Pregnancy
Menopause
Contraceptives
Required
Do any blood relatives have severe headaches?
Yes
No
Required
If yes, Who and Diagnosis:
Which of the following makes the headache better?
Rest
Activity
Darkness
Quiet
Compresses
Scalp or temple pressure
Pregnancy
Menopause
Required
PERSONAL HISTORY
Cig (#/day/#yrs):
Alcohol (oz./day):
Coffee (cups/day):
Are you or have been:
Depressed
Anxious
None
Required
Previous professional treatment of headache?
Yes
No
Required
Previous x-ray or other investigations of headache?
Yes
No
Required
If yes, describe:
Previous medications for headache?
Yes
No
Required
If yes, Name/dosage:
Other current medications? Please list (include over-the-counter drugs):
Drug Allergies:
Comments: