Academy Asthma, Allergy, & Sinus Center
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- Annabelle Willis
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1 This questionnaire is designed to help patients with headaches. No doctors or pharmaceutical companies will profit from this questionnaire. Our only goal is to gather data on patients with headaches to help them in the future. Name: Date Completed: Age: Regular MD: Physician Phone #: Sex: Current Occupation: Telephone #: Home #: Work #: Marital Status: (please circle) Single Married Separated Divorced Widowed Widower Other: If you have suffered from different types of headaches, please answer the questions on this page for your most common type of headache. Describe each type of headache, triggers, etc. separately as outlined in the following pages. Headache History: How long have you had headaches? When did your current headaches start? How old were you when you first started having headaches? The type of headache that you have now have you had them at any time in the past? (please circle) Y or N Headache Description: ONSET Do you have any warning before a headache? Y N If yes, describe: What is the first thing that happens? Where does the pain start and how does it spread? Does it start gradually and then become worse? Y N How long does it take to reach its peak? Is there any particular time of day that it is more painful? Y N If so, describe: Do you wake up with headaches? Y N Do headaches wake you from a sound sleep? Y N TYPE OF PAIN How would YOU describe your headaches? (please circle) Throbbing Pulsating/Pounding Dull Ache Sharp (if so, where?) Stabbing (if so, where?) Tight band across forehead Pressing quality LOCATION Is it only on one side? Y N Is it on both sides? Y N Does it switch sides? Y N
2 Please draw a picture of the location of your headaches above DURATION How long does your headache usually last? With medication: Without medication: What is the longest period of time it has lasted? Have you ever been free of headaches? Y N If so, how long are your headache-free periods? FREQUENCY How often do you get headaches? Please circle one: 2-4 days/month 4-15 days/month greater than 15 days/month Is it more frequent in any particular season? Y N If yes, which season? Is it more frequent at any particular time of the month? Y N If so, please describe: Any recent increase in frequency of your headaches? Y N HEADACHE INTENSITY On a scale of 0-10 where 0 means no headache and 10 means the worst headache you have ever had, please rate the following: How would you rate your headaches today? How would you rate your headaches on a good day? How would you rate your headaches on a bad day? Mild 1-3 Can do all daily activities Mod 4-6 Can do important activities only Severe 7-9 Cannot do daily activities at all 10 = need ER visit/hospitalization How many bad days do you have in a month? How many good days do you have in a month? How many days are you free of headaches in a month? Another guide is below: Any recent increase in intensity of your headaches? Y N
3 ASSOCIATED SYPMTOMS: Check all that apply Y/N Before During After Duration Blurred vision/blindness in one/both eyes Can see only half of an object Light flashes Zigzag lines Nausea Vomiting Light sensitivity Noise sensitivity Dizziness Ringing in the ears Abdominal pain/diarrhea Neck pain/neck stiffness Nasal congestion Eye tearing Eye redness Face/scalp tenderness/swelling/redness Face/arm/leg numbness/tingling/weakness Difficulty with talking/understanding Eyelid droop Double vision Numbness around the lips Loss of consciousness Seizures Please describe all associated symptoms of your headache: Tell us causes such as foods, odors, activities, etc. that trigger your headache:
4 FOODS ODORS ACTIVITIES MISCELLANEOUS CHECK ANY OF THE FOLLOWING THAT CAUSE/WORSEN YOUR HEADACHE: Cheeses Chocolate Chinese food (MSG) Cured meats Red wine Perfume/cologne Smoke Walking stairs Exercise Bending forward Sex Moving your neck Standing position Stress/anxiety Lack of Sleep Oversleeping Bright sunlight Loud sounds Altitude Humidity Alcohol Chewing food Brushing teeth Washing your face Cold air on your face CAUSES MARK ANY OF THE FOLLOWING THAT HELP YOUR HEADACHE WORSENS Medication Y N If so, which? Cold Compresses? Y N Sleeping in a dark room? Y N Coffee? Y N Pressure with your fingers on your temples? Y N Lying flat? Y N PREVIOUS WORK UP FOR HEADACHE Have you ever had a CT or MRI scan of the head? Y N If so, when? If so, where? Have you ever seen a Neurologist for headaches? Y N If so, who? If so, where? Have you ever had a spinal tap? Y N If yes, where, when & why? Have you ever had a test called an EEG? Y N If yes, where, when & why?
5 MEDICATIONS YOU CURRENTLY TAKE OR HAVE TRIED FOR HEADACHES: Imitrex 50 mg tabs, 6 mg injection, 20 mg nasal spray Maxalt 10 mg Amerge 2.5 mg Zomig 5 mg Aspirin/Tylenol/Anacin Motrin/Aleve/Naprosyn Indocin/Clinoril Exedrin/Excedrin Migraine Tylenol/Fiorinal with Codeine Vicodin Did it help Side Effects How many do you take? Y N In one day In one month Please list medications not listed above: PREVENTIVE MEDICATIONS YOU CURRENTLY OR HAVE TRIED FOR YOUR HEADACHES: Circle those medications that apply Did it work? Side Effects? Dose How long did Y N you take this? Inderal/propranolol Tenormin/atenolol Calan/verapamil Elavil/amitriptyline 10 mg Sinequan/doxepin 10 Depakote Tegretol Neurontin Dilantin ALTERNATIVE METHODS Acupuncture Y N OF TREATMENT Biofeedback Therapy Y N YOU HAVE TRIED Yoga/Meditation Therapy/Tai Chi Y N Herbal Therapy Y N Please list medications not listed above: _
6 PAST MEDICAL HISTORY (circle all that apply) FAMILY HISTORY PSYCHIATRIC HISTORY Asthma High Blood Pressure Stroke Stomach Ulcers Heart Condition Diabetes Epilepsy TMJ problems Glaucoma Circulation problems in feet Car sickness, childhood Trouble sleeping at night Snoring/Sleep Apnea Any surgery? If so what kind? Y N History of Arthritis in neck Y N Cancer? Y N Immune-Deficiency Disease? Y N Head Injury before Headache onset? Y N Recent whiplash injury? Y N History of Meningitis before Headache onset? Y N History of Drug Abuse before Headache onset? Y N Any of the following family members experience headaches? Mother Father Brother Sister Aunt Uncle Grandfather Grandmother Cousins Any history of Brain Tumor or Aneurysm in the Y Family? Any personal history of depression? Y N Any family history of depression? Y N Any family history of alcohol use/abuse? Y N Any history of physical or emotional abuse? Y N Any history of stress at home? Y N Any history of stress at work? Y N Please describe: N If married, any marital stress? Y N Please describe: ALLERGIES Food Y N Medications Y N Seasonal Y N Hay Fever Y N Please describe:
7 GYNECOLOGICAL HISTORY (WOMEN ONLY) SOCIAL HISTORY At what age did you start having your periods? Are your cycles regular? Y N How often do you get them? Have you had a hysterectomy? Y N Were you ever diagnosed with ovarian cysts? Y N Are your headaches affected by your menstrual cycles? Y N If so, how? Before? During? After? Have you ever been pregnant? Y N If yes, how were your headaches during pregnancy? Better Worse No Change Are you currently taking birth control pills? Y N If yes, any recent change in the strength of the pills? Y N Do you smoke? Y N If yes, how much? How long? Do you drink alcohol? Y N If yes, how much? How long? Do you use recreational Y N Which ones & how often? drugs? Do you drink caffeinated Y N What & how much daily? soda? Do you drink coffee? Y N How many 8 oz cups per day? >10 cups Do you exercise? Y N How many times/week? If not, why not? Do you eat your meals on time? Y N If not, why not? What do you normally have for breakfast/lunch/dinner/ snack? Do you get at least 7-8 hours of sleep? Y N What time do you go to sleep? What time do you wake up? Do you feel well rested when you wake up? Do you commute to work? Y N If you do, how long is the commute? If so, how old are they? Have you had any recent stressful events? Please describe: Do you have children to care for at home? Y N
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N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
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Date: Staff only: Weight: Height: BP: Pain Age Patient Name Date of Birth Street Address City State Zip Code Home Phone Work Phone Cell Phone Right handed Left handed Please mark one Referring Physician
Preparing for your Appointment: HEADACHE. How bad is your typical headache pain on the 0-10 pain scale with 10 being the worst pain?
Preparing for your Appointment: HEADACHE Write down your symptoms: When did the headaches begin? Where are your headaches located? How bad is your typical headache pain on the 0-10 pain scale with 10 being
APPLICATION FOR CARE AT LAUNCH CHIROPRACTIC
Whom may we thank for referring you to this office? APPLICATION FOR CARE AT LAUNCH CHIROPRACTIC Today s Date: PATIENT DEMOGRAPHICS HRN: Name: Birth Date: - - Age: o Male o Female Address: City: State:
RHEUMATOLOGY PATIENT HISTORY FORM
!! RAMOS RHEUMATOLOGY, PC RHEUMATOLOGY PATIENT HISTORY FORM Date: / / NAME: Birthdate: / / Last First M. I. Age: Sex: F M Marital status: Never married Married Divorced Separated Widowed Partnered/significant
ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address
ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address Home phone number MD Phone number Work number Any other MD you request we send information to?
DATE: / / 7509 E. Main Street Reynoldsburg, Ohio Telephone: (614) Fax: (614)
1275 Olentangy River Rd. Ste 120 Columbus, Ohio 43212 Telephone (614) 291-5555 Fax: (614) 291-7720 Dr. David B. Kaplansky Dr. Randall Contento PATIENT Dr. INFORMATION Garrett Kalmar FORM www.columbusohiopodiatrist.com
New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:
New Patient History Name: DOB: Sex: Date: Chief Complaint: 1. Give a brief description of the problem you are seeking treatment for today: 2. Have you been evaluated for this problem or had any tests for
BROADWAY SPORTS & INTERNAL MEDICINE, P.S TH AVE NE SUITE 202 BELLEVUE, WA P: F:
BROADWAY SPORTS & INTERNAL MEDICINE, P.S. 1600 116 TH AVE NE SUITE 202 BELLEVUE, WA 98004 P: 206 215-2288 F:206 215-2289 MEDICAL HISTORY QUESTIONNAIRE Date Name Date of Birth HT WT Current Medical Complaints
Allina Health United Lung and Sleep Clinic
Medical History Form Date Allina Health United Lung and Sleep Clinic Name Last First MI Date of birth What lung problem do you want us to help you with: Who is your primary care provider? Social History
*521634* Sleep History Questionnaire. Name of primary care doctor:
*521634* Today s Date: Sleep History Questionnaire Appointment Date: Please answer the following questions before coming to your appointment. Please arrive 15 minutes early with this packet filled out.
Medical History Form
Medical History Form NAME DOB / / TODAY S DATE MEDICAL HISTORY What medical Conditions do you have? Select all that apply, or write in if not listed: Diabetes High Blood Pressure Thyroid Disorder Heart
Integrative Consult Patient Background Form
Let Us Know More - So We Can Help Thank you for choosing to schedule an integrative medicine consultation with UC Health. To help us meet your needs during your visit, please take some time to sit in a
634 N. STATE STREET, WESTERVILLE OH, (614) 901-WELL
eas 634 N. STATE STREET, WESTERVILLE OH, 43082 (614) 901-WELL www.abilitychiro.com Name: Age: Date: Address: City: State: Zip Code: Alternate Address: City: State: Zip Code: Cell Phone: ( ) Cell Phone
Surgical History Please list all operations and dates:
1 General Information *Please complete in blue or black ink only* Name: Date: Address: City: State: Zip Code: Date of Birth: Email: Telephone: (Cell) (Home) (Work) Referred by: Occupation: Primary Doctor:
New Patient Questionnaire
New Patient Questionnaire Name: Primary Care Physician: Date of Birth: / / Home Phone: ( ) Cell Phone: ( ) Why are you seeing a cardiologist? (please answer in detail) Have you ever seen a cardiologist