Patient Name:

Email:

Date of birth (mm/dd/yyyy):

On what part of the head do the headaches start (check all that apply)?

After the headache starts - Does it usually:

Stay in one place Move around

Please explain:

How would you describe the pain (check all that apply)?

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?

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?

Do your headaches interfere or prevent normal activities - work etc.?

Yes No

How long ago did the current headaches start?

Weeks Months Years

How many?

How old were you when any headache started?

How long does the headache usually last?

Minutes Hours Days Constant

If minutes/hours/days, how many?

How often does the headache occur?

If days/weeks/months/years, how many?

Does the headache awaken you from sleep?

Yes No

Is the headache getting...

Worse Better Fluctuating No change

DO ANY OF THE FOLLOWING SYMPTOMS OCCUR EITHER BEFORE,
DURING OR AFTER THE HEADACHE?

General (check all that apply):

Face/Scalp (check all that apply):

Neck (check all that apply):

NoneMuscle tenderness(right)
Muscle tenderness(left)Stiffness(right)
Stiffness(left)

Hands and/or feet (check all that apply):

Eyes (check all that apply):

Arms/legs (check all that apply):

NoneArm numbness/tingling(right)
Arm numbness/tingling(left)Leg numbness/tingling(right)
Leg numbness/tingling(left)

Indicate if any of the following factors have brought or worsen your headache (check all that apply):

Do any blood relatives have severe headaches?

Yes No

If yes, Who and Diagnosis:

Which of the following makes the headache better?

PERSONAL HISTORY

Cig (#/day/#yrs):

Alcohol (oz./day):

Coffee (cups/day):

Are you or have been:

Depressed Anxious None

Previous professional treatment of headache?

Yes No

Previous x-ray or other investigations of headache?

Yes No

If yes, describe:

Previous medications for headache?

Yes No

If yes, Name/dosage:

Other current medications? Please list (include over-the-counter drugs):

Drug Allergies:

Comments:

NEUROLOGY SCHEDULING

Headache Questions