HEADACHE HISTORY. Indicate the area of your head where your headaches seem to be concentrated. Please check those that apply:
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- Wilfrid French
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1 HEADACHE HISTORY Name Date It may seem strange to ask a person where his headache hurts, but the exact location in the head is important to help us make an accurate diagnosis. Please read through the entire history, then answer each question to the best of your ability and as accurately as possible. If uncertain, leave blank. 1. Location Indicate the area of your head where your headaches seem to be concentrated. Please check those that apply: A. Always on one side ( R ) ( L ) B. Alternates C. Always on both sides D. Over eyes E. In eyes F. Under eyes G. Between eyes H. Behind eyes I. In temples J. In teeth K. Over cheeks L. In top of head M. In side of head N. In back of head O. In neck - back P. In ears Q. Other 2. How long have you had these headaches? A. They have become: More Severe Less Severe Same Severity More Frequent Less Frequent Same Frequency B. They occur: 1. Daily 2. Weekly 3. Monthly 4. Periodic (several headaches followed by period of no headaches, only to recur several months later).
2 C. They begin: 1. Slowly (over minutes). 2. Abruptly D. They last: 1. Seconds 2. Minutes 3. Hours 4. Days 3. Headaches occur most often: (Please check appropriate blank). A. Upon awakening in A.M. B. Awakened in A.M. by headache C. After getting up D. Late morning E. Later in day F. Late afternoon G. In evening H. Awaken from sleep about 1-3 hours after going to bed I. (In Females) In association with monthly periods J. Every day for several days, then no headaches for periods of time K. Just before meals L. 1-2 hours after meals M. Do you ever miss or skip meals and have headaches occur at time of normal meals? N. Several hours after missing usual meal hour O. Other 4. Headache pain best described as: A. Steady B. Pulsating C. Throbbing D. Shooting (if so, write from where to where) E. Other 5. Headaches are accompanied by: (Please check Yes or No) A. Blockage or obstruction to breathing through nose. 1. If headache on only one side, nose obstructs same side B. Runny nose 1. If headache on only one side, runny nose on same side. C. Redness and watering of eye 1. If headache on only one side, the side of headache
3 D. Changes in eyesight with headaches 1. Flashes of light 2. Decreased area of vision (tunnel vision) 3. Double vision E. Gastro-intestinal Symptoms 1. Nausea 2. Vomiting 3. Abdominal cramps 4. Diarrhea F. Chest symptoms 1. Chest pain 2. Shortness of breath 3. Difficulty breathing 6. List ALL medications you now take including non-prescription drugs (and birth control pills if taken). 7. Is there anything that you know of that brings on a headache? 8. Is there anything that you know of that aggravates a headache? 9. Is there anything that makes your headache better? 10. Does reading or close work make headaches worse? 11. Does exertion make headaches worse? 12. Do you have any of the following diseases? 1. Arthritis 2. Rheumatic disease 3. High blood pressure (Hypertension) 4. Diabetes 5. Chronic kidney disease 6. Ulcers of the stomach 7. Asthma 8. Hay fever 9. Food allergies 10. Chronic constipation
4 13. Please list all illnesses you have had for the past 3 years. 14. Do you smoke? What? How many? 15. Do you use alcohol? How much per day? What form or forms? Beer Scotch Wine Gin Bourbon Vodka Other 16. Does headache ever occur within 30 minutes after use of alcohol? 17. Have you ever had a severe head injury? When? What? How? 18. Have you ever had a severe neck injury? When? What? How? (Auto accident, sports, fall, etc.) 19. Do you have: A. Feelings of tenseness of anxiety with no real cause B. Financial problems C. Marital problems D. Problems with neighbors E. Problems with employer F. Problems with fellow employees G. Problems with children H. Problems with in-laws I. Other
5 HEADACHE DISABILITY INDEX NAME: DATE: AGE: Scores Total: ; E ; F (100) (52) (48) INSTRUCTIONS: Please CIRCLE the correct response: 1. I have headache: [1] 1 per month [2] more than 1 but less than 4 per month [3] more than one per week 2. My headache is: [1] mild [2] moderate [3] severe INSTRUCTIONS: (Please read carefully): The purpose of the scale is to identify difficulties that you may be experiencing because of your headache. Please check off YES, SOMETIMES, or NO to each item. Answer each question as it pertains to your headache only. YES SOMETIMES NO E1. Because of my headaches I feel handicapped. F2. Because of my headaches I feel restricted in performing my routine daily activities. E3. No one understands the effect my headaches have on my life. F4. I restrict my recreational activities (e.g. sports, hobbies) because of my headaches. E5. My headaches make me angry. E6. Sometimes I feel that I am going to lose control because of my headaches. F7. Because of my headaches I am less likely to socialize. E8. My spouse (significant other), or family and friends have no idea what I am going through because of my headaches. E9. My headaches are so bad that I feel I am going to go insane. E10. My outlook on the world is affected by my headaches. E11. I am afraid to go outside when I feel that a headache is starting. E12. I feel desperate because of my headaches. F13. I am concerned that I am paying penalties at work or at home because of my headaches. E14. My headaches place stress on my relationships with family or friends. F15. I avoid being around people when I have a headache. F16. I believe my headaches are making it difficult for me to achieve my goals in life. F17. I am unable to think clearly because of my headaches. F18. I get tense (e.g. muscle tension) because of my headaches. F19. I do not enjoy social gatherings because of my headaches. E20. I feel irritable because of my headaches. F21. I avoid traveling because of my headaches. E22. My headaches make me feel confused. E23. My headaches make me feel frustrated. F24. I find it difficult to read because of my headaches. F25. I find it difficult to focus my attention away from my headaches and on other things. Jacobson Gary P., Ramadan NM, et al., The Henry Ford Hospital headache disability inventory (HDI). Neurology 1994;44:
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Page 1 of 7 GENERAL INFORMATION Name: Date of Birth: Age: Social Security #: Sex: Height: Weight: Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Employer s Name: Marital Status: Married
The failure to bring this information with you may result in the rescheduling of your appointment.
Alan Koester, MD Steven Novotny, MD John Jasko, MD Viorel Raducan, MD Brock Niceler, MD Thomas Reinsel, MD Chad Lavender, MD Thank you for choosing Marshall Orthopaedics! We will make every effort to ensure
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N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
Physician Signature: OrthoNeuro Date: Name: Date: Age: SS#: Sex: DOB: Referring Physician: Referring Physician Address: Mark the areas on the corresponding figures where you feel the described sensations.
Dr. Gary Malstrom B.Sc.(Hon.), D.C., C.Ac Brant Street, Burlington, Ontario L7R 2J9 (905) Fax (905)
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