Current Complaint Please briefly describe the reason for your visit to our office today:
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1 MEDICAL HISTORY Please complete the following information: Patient name: D.O.B. Date: *The following information is very important to us in taking care of your health. Please take the time to fill out all of the information below. Update us with any changes. Current Complaint Please briefly describe the reason for your visit to our office today: Past Medical History Do you have any allergies to medications? Yes No If yes, please list the medications and the associated allergic reaction: List all medications you are currently taking (including over the counter): Name Dose? Name Dose? If yes, please explain: If yes, please indicate: Date/Hospital/City, State/Reason If yes, please indicate: Date/Hospital/City, State/Reason Social History Who lives with you? What are you doing for work? Have you ever smoked? Yes No Do you presently smoke? Yes No If you smoke now, or did so previously, for how many years did you smoke? If you have quit smoking, how long has it been since you stopped? If you smoke, indicate how much for each daily: Cigars: Pipes: Cigarettes: Do you drink alcoholic beverages, and if so, what & how much Yes No Do you drink caffeinated beverages, if so, what & how much? Yes No If you use recreational drugs, please notify your physician. Do you exercise, if so, what and how often? Yes No Family Medical History (i.e. stroke, diabetes, heart disease, headaches, cancer, Parkinson s disease, Alzheimer s disease, Multiple Sclerosis, seizures) M Brother/Sister: Father: Children: Grandparent: Additional Information: 1
2 HEADACHE HISTORY DO YOU HAVE MORE THAN ONE HEADACHE TYPE? Yes No **If yes, please use an additional headache history sheet for each** ONSET OF FIRST HEADACHE: Headaches started years ago. I was: younger than over 50 years old PRECIPITATING EVENT (trigger of first headache): None Known Injury Menarche (first period) Pregnancy Other: FREQUENCY: Headaches occur times each Day Week Month Are headaches increasing? Yes No Headaches are more frequent: Weekdays Weekends Vacations Spring Summer Fall Winter No relation ONSET: Headache onset occurs: gradually suddenly varies And most frequently in the: morning afternoon evening night LOCATION: Starts: left side of head right side of head either side of head both sides of head back of head neck behind eye(s) other: DURATION: Last hours days WITHOUT medications Last hours days WITH medications INTENSITY: With medication: mild moderate severe incapacitating Without medication: mild moderate severe incapacitating DESCRIPTION OF PAIN TYPE: throbbing aching pressure stabbing shooting tight dull burning searing other: HEADACHES EFFECT ON ABILITY TO FUNCTION: Able to function normally Ability to function severely decreased Ability to function slightly decreased Totally bedridden HORMONAL: Headaches are affected by: menstrual cycle pregnancy How? FREE OF HEADACHE from: to never free If never free, when was the last time you went 24 hours without headache? 2
3 HEADACHES CAN BE BROUGHT ON BY: fatigue physical exertion stress weather changes hunger lack of sleep menstruation loud sounds high altitude alcohol too much sleep odors coughing bright lights medications chewing or talking sex/orgasm foods ( which? ) WARNINGS THAT A HEADACHE IS COMING: light flashes numbness upset stomach zigzag lines dizziness weakness blindness lightheadedness ASSOCIATED SYMPTOMS: nausea/vomiting one eye tears sore/stiff neck ringing in the ears odors numbness/tingling both eyes tear concentration lightheadedness dizziness increased urination constipation diarrhea fatigue weakness blurred/double vision increased appetite decreased appetite insomnia memory change in sexual interest anxiety, tension, or irritability other: Sensitive to: lights sounds DURING A HEADACHE, YOU ARE MORE COMFORTABLE: lying down with massage or pressure on scalp when pacing in a dark, quiet room with hot or cold compress chewing or talking PREVIOUS TESTING (please give date & results): MRI: Cervical spine films: CT Scan: Sinus x-rays: EEG: Angiogram: Sleep study: Other: PREVIOUS EVALUATIONS (please give name, date & results): Neurologist: Headache specialist: Internist: Ear, Nose, & Throat Specialist: Dental eval: Eye exam: Psychological Testing: PREVIOUS NON-MEDICAL TREATMENTS AND EVALUATIONS: biofeedback/relaxation/self hypnosis physical therapy chiropractor acupuncture/acupressure nutritional counseling allergy testing ARE YOU CURRENTLY TAKING MEDICATION FOR HEADACHE or HAVE YOU PREVIOUSLY TAKEN MEDICATION FOR HEADACHE? Yes No **If yes, please complete the medication history on the following page** WITH CURRENT MEDICATION, HOW QUICKLY DO YOU FEEL ADEQUATE RELIEF? within 2 hours in more than 2 hours relief is never adequate not currently taking medication 3
4 Please place X in the appropriate column: REVIEW OF SYSTEMS In the past year Never General Weight loss (how much?) Weight gain (how much?) Fevers Shaking chills Trouble sleeping Eyes Double vision Cataracts Blurred vision Loss of vision Ears, Nose, & Throat Ringing in ears Hearing loss Hoarseness Cardiovascular Heart murmur or fainting High blood pressure Chest pain or tightness Hear t attack Palpitations History of irregular pulse Respiratory Chronic cough Shortness of breath Gastrointestinal Abdominal pain Vomiting Recent change in bowel habits Bleeding Genitourinary Pain when voiding Frequent urination Dribbling after urination Blood in urine Musculoskeletal Back pain Arthritis (note in joints) Neck pain In the past year Never Dermatological Rashes Neurological Frequent headaches Loss of speech/speech change Tremor or shaking Numbness in extremities Numbness in face Convulsions (seizures) Stroke Psychiatry Depression Anxiety Memory loss Endocrine Cold intolerance Heat intolerance Age of onset of menses Last menstrual period If female, are you pregnant? Yes No Are you planning to become pregnant? Yes No (If you become pregnant, please inform your provider immediately) Hematology Easy bruising Bleeding Allergy Hay fever Allergic rash To the best of my belief, the above information is true and accurate. Signature: 4
5 Circle medications taken in the past: Prophylactics Blocadren or Timolol Corgard or Nadolol Inderal or Propanolol Lopressor/Metoprolol/Toprol Tenormin or Atenolol Bystolic Cardizem/Diltiazem Covera, Verelan, Calan, Verapamil Norvasc Procardia or Nifedipine Catapress or Clonidine Zestril Prinivil or Lisinopril Atacand Neurontin/Gabapentin Lyrica Dilantin/Phenytek/Phenytoin Tegretol, Carbatrol or Carbamazepine Trileptal Depakote/Valproic Acid Topamax Lamictal Zonegran Phenobarbital Keppra Elavil or Amitriptyline Pamelor or Nortriptyline Trazadone Desipramine Tofranil or Imipramine Wellbutrin or Bupropion Prozac or Fluoxetine Zoloft or Sertraline Paxil Luvox Celexa Lexapro Effexor Cymbalta Pristiq Current medications: Prophylactics (cont) Savella Eskalith, Lithobid or Lithium Nardil Parnate Mexilitine Methergine Haldol Zyprexa Geodon Seroquel Risperdal Abilify Muscle Relaxants Zanaflex or Tizanidine Soma or Carisoprodol Baclofen/Lioresal Skelaxin or Metaxalone Amrix Flexeril/Cyclobenzaprine Robaxin or Methocarbamol Sleep aides/anxiety Xanax or Alprazolam Ativan or Lorazepam Valium or Diazepam Librium or Chlordiazepoxide Klonopin or Clonazepam Buspar or Buspirone Sonata Ambien Rozerem Lunesta Procedures Greater Occipital nerve block Trigeminal nerve block Botox Amount injected? Anti-nausea Benadryl or Diphenhydramine Compazine or Prochlorperazine Reglan or Metoclopromide Phenergan or Promethazine Thorazine or Chlorpromazine Vistaril or HydroxyzineAbortives Abortives Midrin, Amidrin or Isomepthene Imitrex/Treximet Zomig Amerge Maxalt Axert Frova Relpax DHE-45 Migranal Nasal Spray Ergostat Ergotamine or Ergomar Cafergot Rescue Medication Tylenol Anacin or Excedrin Motrin, Advil or Ibuprofen Anaprox, Aleve, Naprelan, Naprosyn or Naproxen Sodium Orudis, OruVail or Ketoprofen Voltaren, Cataflam, Arthotec or Diclofenac Toradol or Ketorolac Lodine or Etodolac Relafen or Nabumetone Indocin or Indomethacin Mobic or Meloxican Ansaid or Flurbiprofen Celebrex Prednisone/Dexamethasone/Medrol pack/depo-medrol Solumedrol/Decadron 5
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