Head Pain Intake Form

Transcription

1 Head Pain Intake Form NEUROLOGY LLC Your evaluation will take one hour to complete and in order to best utilize the time, please take the time to complete this questionnaire prior to your appointment. Please answer ALL of the questions on this form. Your careful attention to detail is very important because it allows it allows the physician to design the most appropriate type of evaluation and treatment program especially for you and your specific problem. Name: Date: Headache History/Description My primary headache problem started years ago. Did you have an accident that may have started your headaches? Yes Do you believe that some other event in your life started your headaches? Yes If yes, please explain: What is your goal for coming to? Prior headache history: Family history of head pain? Yes If yes, check the following who have head pain in your family: Parent Sibling Child Do you have more than one type of headache? Yes How many days per month do you have headache? Least/per month: Most/per month: Is it increasing in frequency? Yes Is it increasing in duration? Yes Is it increasing in severity? Yes How would you describe your pain?: Throbbing/Pulsating Sharp Pressing/Squeezing Dull/Nagging Tight Band Stabbing Other (Describe): Where is your pain? One Side Both Sides Whole Head

2 NEUROLOGY LLC Headache Symptoms (Please check all of your symptoms at the time of your headaches): Gastrointestinal Sensory Vasomotor Visual Decreased Appetite Scalp Tenderness Chills Light Sensitivity Nausea Tingling Flushing Blurred Vision Vomiting Numbness Stuffy Nose (R / L) Double Vision Diarrhea Ringing in Ears Runny Nose (R / L) Spots (in Front of Eyes) Constipation Noise Sensitivity Cold Hands/Feet Zigzag Line Odor Sensitivity Pale or Bluish Hands/Feet Bright Spots Mental Eyes Watering (R / L) Poor Concentration Memory Difficulties Confusion Motor Emotional General Blind Spots Colors Eyelid Droop (R / L) Trouble Speaking Depressed No Energy (Lethargic) Vestibular (saying right words) Irritable Fatigue Trouble with Balance Restless Neck Pain Dizzy/Unsteady Trouble Moving Anxious or Nervous Back Pain Sensation of Movement (extremities) Frustrated Aura Fainting Other: Headache Triggers (Please check all of the following that you feel may trigger or start your severe headache): Alcohol Fasting Lack of Sleep Too Much Sleep Weekends Vacations Food Sex Orgasm Exertion Medication Seasonal Altitude Emotions Stress Allergies/Sinus Odors Let Down Menses Weather Sun Bright Light Headache Durations How long does your headache usually last? Shortest: Longest: Is it constant? Since this headache began, what has been the longest headache free period? Hours/Days Days/Weeks *** FOR WOMEN ONLY *** Menstrual Period Ovulation Time Before Menstruation Pregnancy Menopause Contraceptives Other Hormone Therapy

3 NEUROLOGY General Headache Information (Please list for the past week) : Number of mild headaches Number of moderate headaches Number of severe headaches My headache usually starts: During the night During the day Upon awakening Unpredictable Time missed from work: (please circle) days weeks months How many emergency room visits have you made from headache? (please circle) per week / month / year How dysfunctional are you because of headache? Mild Moderate Severe Sleep I have difficulty falling asleep I need medication(s) to fall asleep Please list: Headache awakens me from sleep How many times per night, if at all? I have difficulty staying asleep for reasons other than headache I awaken earlier than usual Other things I do to help me sleep: Personal Habits Caffeine: cups of coffee/day cups of tea/day 12 oz cans of soft drinks/day Tobacco: cigarettes packs/day I am trying to quit tobacco use Other Substances: alcohol amount per day marijuana cocaine Other recreational drugs: I get some form of exercise on a regular basis. If so, list type and frequency: Diagnostic Imaging History What diagnostic tests have you had relating to your headaches? Neurological examinations How many? CT- Head & Neck How many? EEG How many? MRI- Head & Neck How many?

4 Past Medical History (Please circle all applicable) Do you or have you ever had any problems with the following: Hypertension Yes No Diabetes Yes No Heart Yes No Stomach Pain Yes No Ulcers Yes No Liver Yes No Thyroid Yes No Unexplained Fevers Yes No Sweats Yes No Chills Yes No Loss of Appetite Yes No Weight Loss More than 10 lbs. Yes No Difficulty Sleeping Yes No Sexual Functions Yes No Chronic Tiredness Yes No Circulation Yes No Coughing Up Blood Yes No Chest Pain Yes No Swollen Ankles Yes No Difficulty Urinating Yes No Blood in Urine Yes No Stiff or Swollen Joints Yes No Easy Bruising or Bleeding Yes No Dizziness Yes No Fainting Yes No Depression Yes No Nerves/Anxiety Yes No Bowel Problems: Constipation Yes No Diarrhea Yes No Incontinence Yes No Bladder Problems: Retention Yes No Frequency Yes No Incontinence Yes No History of Motion Sickness Yes No History of Head Trauma Yes No History of Cold Hands/Feet Yes No NEUROLOGY Explanation: Family History:

5 NEUROLOGY Medications Please list any medications you are allergic to: (1) (2) (3) (4) Please check each medication you have used for headache or other reasons: Anti-Inflammatories Orudis Naprosyn Anaprox Motrin Ibuprofen Advil Aleve Indocin DayPro Cataflam Voltaren Lodine Relafen Toradol Celebrex Antidepressants Elavil Pamelor Prozac Zoloft Paxil Effexor Welbutrin Zyprexa Celexa Abilify Lexapro Prestiq Cymbalta Antimigraine Medications Methergine Sansert DHE Frova Midrin Imitrex Maxalt Zomig Amerge Migranal Treximet Sumavel Relpax Axert Antinausea/Phenothiazines Phenergan Compazine Tigan Reglan Decongestants/Antihistamines Benadryl Vistaril Antivert Periactin Heart/Blood Pressure Cardene Veralan Verapamil Corgard Lopressor Tenormin Inderal Propranolol Timolol Lisinopril Neuromodulators Topamax Depakote Lyrica Keppra Neurontin Sleeping Pills/Tranquilizers Ambien Lunesta Xanax Ativan BuSpar Halcion Dalmane Restoril Klonopin Steroids Prednisone Hydrocortisone Decadron Medrol Alternatives Petodolex Magnesium CoQ Vitamin B Vitamin D3 Botox Other Vimpat Aricept Namenda List any other medication(s) that you use for headache that does not appear on the above list: (1) (2) (3) (4)

6 NEUROLOGY Medications Please list all medications you are taking or have taken (including over-the-counter medications such as Tylenol, birth control pills, hormones, cold and sinus medication, etc.); being very specific. Follow the example below and indicate the actual number of times and number of days of the week you are taking the medication, even if it is not on a daily basis. PLEASE DO NOT USE PRN, AS NEEDED. EXAMPLE: