HEADACHE HISTORY & PROFILE QUESTIONNAIRE
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1 1 HEADACHE HISTORY & PROFILE QUESTIONNAIRE Patient Name: On what part of the head do your headaches start? R Side L Side Either Side Both Sides Back On Top Temples Behind/AroundEyes Forehead Face Neck Other How long ago did you current headache start? Days Weeks Months Years How many years ago did your headaches start? How long do your headaches usually last? Minutes Hours Days Constant How often do your headaches occur? x/day x/week x/month x/year Constant Is the headache getting - More Severe More Frequent Both After the headache starts, does it usually - Stay in one place Move around Please explain: How would you describe the pain? Throbbing Pulsating Pressing Squeezing Stabbing Sharp Dull/Nagging Other Describe the degree of pain when your headaches start: Describe the degree of pain with most of your headaches: Describe the degree of pain with your worst headaches:
2 2 ASSOCIATED HEADACHE SYMPTOMS: Are any of the following symptoms associated with your headaches? Please mark (B) before (D) during (A) after Spots before eyes/type Blindness (R/L) Blurring (R/L) Eyelid Droop (R/L) Can see only ½ of objects Tearing Double Vision Eye Redness (R/L) Puffy Eyes (R/L) Light Sensitivity Noise Sensitivity Odor Sensitivity Stuffy Nose Runny Nose ABDOMINAL: Nausea Vomiting Stomach Cramps Hunger Diarrhea Loss of Appetite FACE/SCALP: Pale Redness Sweating Tender Pain while Chewing Puffy Decreased Jaw Opening STATE OF MIND: Depression Fatigue Anxiety Irritability Difficulty Concentrating Difficulty Talking (finding words) Difficulty Understanding Dizzy Fainting (feeling like or actuality) HANDS AND/OR FEET: Cold Pale Sweaty Mottled WEAKNESS (W) NUMBNESS (N) BOTH (B) Face (R/L) Arms (R/L) Legs (R/L) Arm & Leg (R/L) Do you have an aura with your migraines? Yes No If yes, what is your aura? Which of the following makes the headache better? Rest Quiet Pregnancy Activity Hot compress Menopause Darkness Cold compress Scalp/Temple Pressure Indicate if any of the following factors have: (+) brought on a headache or (++) worsen your headaches Sleep too much/too little Sexual Activity Chocolate Emotional Stress Medications (include over the counter/supplements) Missed Meals Citrus Fruit Menstrual periods Depression/anxiety Change in weather Chesses Pregnancy Physical activity Seasons MSG Menopause Erect position Alcohol Other foods (list) Oral contraceptives Bending Process meat Straining Coughing Over eating Dehydration Too much caffeine Infections Relief of stress High altitude Head injury Driving at night Bright lights, Loud sounds, Strong smells
3 3 LIST THE MEDICATION(S) THAT YOU ARE USING OR HAVE USED IN THE PAST TO PREVENT OR ABORT YOUR HEADACHES: MEDICATION PRESENTLY USING TRIED IN THE PAST EFFECT ON HEADACHE WORSENED/IMPROVED UNCHANGED/DON T KNOW
4 4 IN ADDITION TO THE ABOVE LISTED MEDICATIONS, WHICH OF THE FOLLOWING HAVE YOU USED FOR TREATMENT OF YOUR HEADACHES? THERAPY NEVER USED PRESENTLY USING TRIED IN THE PAST EFFECT ON HEADACHE WORSE/IMPROVED UNCHANGED/DON T KNOW ACUPUNCTURE BIOFEEDBACK AROMATHERAPY CHIROPTACTIC TREATMENT RELAXATION THERAPY COGNITIVE THERAPY/PSYCHAPY REFLEXOLOGY MASSAGE AVOIDNESS OF FOODS AND/OR DRINKS THAT TRIGGER HEADACHE AVOIDNESS OF ACTIVITIES THAT TRIGGER HEADACHES
5 5 Do your headaches interfere or prevent normal activities? Work, school, etc Has your productivity at work or school been affected by your headaches? In the last month have your headaches caused you to miss: Leisure/Social/Work/School? In the last 6 months have your headaches caused you to miss: Leisure/Social/Work/School? Do any of your blood relatives have severe headaches? If yes, who? Do you have a history of head or neck injury? If yes, did it involve loss of consciousness? LIFESTYLE: Do you exercise regularly? If yes, how often? Do you frequently skip meals? How much caffeine do you eat/drink in a day? (Coffee, tea, soda, chocolate etc) Do you smoke cigarettes? If yes, how many per day? How long have your smoked? Do you drink alcohol? If yes, how many oz per day? Do you drink coffee/tea? If yes, how many cups per day? Do you have a problem sleeping? Do your headaches wake you up? Do you wake feeling rested? Are you or have your been: Depressed Anxious
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Date: / / NAME: Last First M. I. Age: Sex: q F q M Birthdate: / / What specific questions or goals do you have for this appointment? Please list the names of other clinicians you have seen for this problem:
The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.
Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information