HEADACHE QUESTIONNAIRE
My headaches started on: I get headaches about every: day week month three-months year My headaches last: seconds minutes hours days Describe the head pain you experience
  • throbbing
  • pulsating
  • pounding
  • constant
  • tight
  • squeezing
  • pressure
  • sharp
  • grinding
  • vise-like
  • hat-band
  • tender
  • other:
  • My headaches are located
Associations
  • Headache is accompanied by
  • diarrhea
  • dizziness
  • drooping eye lid
  • facial tenderness
  • fever
  • flushing on one side of the face
  • light sensitivity
  • loss of consciousness
  • nausea or vomiting
  • neck stiffness
  • noise sensitivity
  • numbness in face/arm/leg
  • red, tearing eye
  • runny nose/congestion
  • swelling of ankles
  • speech disturbance
  • visual disturbances
  • weakness in face/arm/leg
  • other:
Is your head pain triggered by any of the following:
  • other:
  • Alcohol
  • Barometric pressure or weather
  • Bending over
  • Blood Pressure
  • Certain foods (such as cheese or Chocolate)
  • Colds
  • Coughing
  • Depression, anxiety, nerves, or stress
  • Exertion
  • Fatigue
  • Heat, hot showers
  • Head movement
  • Menstrual periods
  • Missing a meal
  • Monosodium glutamate (MSG)
  • Odors
  • Salt
  • Sex
  • Seasons
  • Swallowing
  • Sleep or Lack of sleep
  • Time of day
Is your head pain relieved by any of the following:
  • Cold compresses
  • Eating
  • Heat
  • Massage
  • Medication (which ones ?)
  • Moving around
  • Relaxation
  • Sleep
  • Vomiting
Life Style / Habits
  • How many alcoholic drinks per day ?
  • How many caffeinated drinks per day
  • How many hours do you sleep per day ?
  • Do you smoke cigarettes, cigars or pipes ?
  • Are you currently involved in litigation with respect to any medical problems ?
  • Are you usually highly stressed ?
  • Do you usually eat 3 meals/day ?
Injuries
  • head
  • neck (for example whiplash)
  • dental work preceding onset of headache ?
Exposures or Infections
  • Carbon Monoxide (car or house)
  • Venereal Disease or Syphilis ?
  • Tuberculosis or Cysticercosis ?
MEDICATIONS
What are your current medications, include hormones, birth control pills, vitamins, etc. (Name and amount/day Have you ever taken any of the following medicines for headache
  • Abilify
  • DHE
  • Mexetil
  • Sinutab
  • Adipin
  • Duradrin
  • Micranin
  • Skelaxin
  • Acetaminophen
  • Duragesic
  • Midol
  • Soma
  • Advil
  • Ecotrin
  • Midrin
  • Stadol Nasal Spray
  • Alleve
  • Effexor
  • Migranol
  • Sumatriptin (triptan)
  • AlkaSeltzer
  • Elavil (amitryptyline)
  • Motrin
  • Surmontil
  • Amerge (triptan)
  • Empirin
  • Naprosyn
  • Talwin
  • Amitriptyline
  • Ergomar (ergot)
  • Neurontin
  • Tenormin
  • Anacin
  • Ergostat (ergot)
  • Nimodipine
  • Thorazine
  • Anafranil
  • Esgic
  • Norflex
  • Timonol
  • Antihistamines
  • Equigesic
  • Norgesic
  • Topamax
  • Asendin
  • Excedrin
  • Norpramin
  • Toprol
  • Aspirin
  • Fentanyl patch
  • Nortriptyline
  • Torecan
  • Axert (triptan)
  • Feverfew
  • Nubain
  • Trexan
  • Axotal
  • Fiorinal
  • Nuprin
  • Triavil
  • Aventyl
  • Fioricet
  • Oxygen
  • Trilifon
  • Baclofen
  • Flexeril
  • Oxycontin
  • Trileptal
  • Bellergal
  • Gabapentin
  • Pamelor
  • Tylox
  • Beta-blocker
  • Ibuprofen
  • Panadol
  • Tylenol
  • Blockadren
  • Imitrex
  • Parafon Forte
  • Tylenol #3 or #4
  • Bufferin
  • Inderal (propranolol)
  • Parnate
  • Vanquish
  • Cafergot
  • Indocin
  • Paxil
  • Venlafaxine (Effexor)
  • Calan (verapamil)
  • Indomethacin
  • Pertofrane
  • Verapamil (Calan)
  • Cardene
  • Isoptin
  • Percocet
  • Verelan (verapamil)
  • Cardizem
  • Lamictal
  • Percodan
  • Viskin
  • Catapres
  • Lexapro
  • Percogesic
  • Vivactyl
  • Corguard
  • Limbitrol
  • Periactin (cyproheptadine)
  • Vicodin
  • Codeine
  • Lithium
  • ohenergan
  • Wellbutrin
  • Cymbalta
  • Liorisal
  • Phrenilin
  • Wigraine
  • Cyproheptadine
  • Lopressor
  • Procardia
  • Zomig
  • Darvon/Darvocet
  • Lortabs
  • Propranolol (inderal)
  • Zonegran
  • Datril
  • Lorcet
  • Prozac
  • Zoloft
  • Dapro
  • Ludiomil
  • Reglan
  • Desyril
  • Lyrica
  • Relpax (triptan)
  • Herbal products
  • Dilantin
  • Magnesium
  • Robaxin
  • Petadolex
  • Decongestants
  • Marplan
  • Serzone
  • Demerol
  • Maxalt (triptan)
  • Sansert
  • Depakote
  • Methadone
  • Sinequan
Past Medical History, Review of Systems
My health has been affected by Treatment by a
  • General Health
  • psychiatrist
  • Lyme disease
  • Problems
  • or counselor