HEADACHE QUESTIONNAIRE
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- Malcolm Lambert
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1 HEADACHE QUESTIONNAIRE 1. How long have you experienced headaches (include all types)? 2. How old were you when you first had headaches (of any type)? 3. When was your last headache? 4. How severe are your headaches on average on a scale of 0 to 10 with 0 being no pain and 10 being the worst imaginable pain? ; On the same scale how would you rate your worst headache? 5. On average how often do you have headaches ( of any type) 6. On average how long do your headaches last? 7. Do you have a history of head trauma? Date: If so please describe: 8. Do your headaches tend to come on as attacks (are sudden)? Sometimes Usually Always 9. How would you describe the quality of the pain? Throbbing, pulsating, pounding Stabbing /boring Pressing/tightening Dull Squeezing 10. Does the pain usually occur on one side of your head? _No Which side? Right Left Both Don t Know 11. Are your headaches associated with significant: (check all applicable): tearing in one eye redness in one eye runny nose only on one side 12. Does exertion (of any kind including walking) have an effect on your headache? Change Worse Better Don t Know 13. Does sleep have any effect on your headache? Change Worse Better Don t Know 14. Does bending your head forward, coughing or sneezing have any effet on your headache? Change Worse Better Don t Know
2 ON THE DIAGRAM BELOW CIRCLE THE LOCATION OF YOUR PAIN 15. Have you noticed any association between ingesting any food or beverage and your headaches? Cheese Chocolate Nuts Coffee Soda Alcohol OTHER: 16. Do you ever experience visual changes before or during your headaches? 17. If yes which of the following visual symptoms do you experience? Flickering or flashing lights, showers of light? Never Sometimes Often t Sure Blurred vision? Never Sometimes Often t Sure Dark spots before your eyes? Never Sometimes Often t Sure Partial or complete loss of vision? Never Sometimes Often t Sure Zigzag lines, geometric shapes, stars? Never Sometimes Often t Sure
3 18. How long do your visual symptoms usually last? SECONDS MINUTES HOURS DAYS 19. Are your headaches accompanied by any problem? Speech? Never Sometimes Often t Sure Thinking? Never Sometimes Often t Sure Difficult word finding? Never Sometimes Often t Sure Sensations (numbness, weakness, tingling?) Never Sometimes Often t Sure Hearing problems? Never Sometimes Often t Sure Imbalance? Never Sometimes Often t Sure Buzzing or ringing in ears? Never Sometimes Often t Sure 20. How much time generally elapses between the beginning of the earliest (neurological change) and the onset of the headache? SECONDS MINUTES HOURS DAYS 21. Are you usually able to tell when a headache is about to occur? 22. Do you ever feel nauseated, sick to your stomach, experience vomiting or have diarrhea or other digestive problems with your headaches? 23. Does light usually bother you during a headache? 24. Does noise (i.e. radio, TV, voices, moving a chair across the florr) usually bother you during a headache? 25. Do particular odor (i.e. perfume, food, gasoline, smoke) bother you during a headache?
4 WOMEN ONLY: 26. Date of your LMP: 27. Do you have an irregular menstrual cycle? 28. Do you use Birth Control If so, What type? 29. Do you have a history of Polycystic Ovarian Disease? 30. Are these headaches ever associated with your mentrual cycle? 31. When do your headaches begin, with respect to your period? 32. Do you experience any sleep problems or disorders? If so, what? 33. Do you snore? 34. Do you suffer from any Dental Problems? 35. Do you suffer from TMJ or teeth grinding? 36. Do you have a history of anxiety or depression? If yes, are you being treated with medication, which one? If yes, who is your treating physician? Physician name: Address: Phone: FAMILY HISTORY 37. Does anyone in your family suffer from headaches? Who?
5 38. Please provide any family history pertaining to your headaches. MEDICATION HISTORY 39. Do you currently take any prescribed medications to treat your headaches? 40. Do you currently take non-prescribed or over-the-counter medicines for headaches? 41. Please tell me which medications you have tried. NAME OF DRUG HELPED? 42. Please provide additional information about your headache
6
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