NISA Headache Questionnaire

Transcription

1 NISA Headache Questionnaire Patient: Date: What prompted this headache appointment? Headache (HA) Duration: How many days a (circle one) week / month do you have headaches? How many (circle one) weeks / months / years has that pattern been going on? How many days a (circle one) week / month do you have what you would call a severe HA? Before pattern above, (1) how many days a (circle one) week / month would you have HAs? (2) how long had that pattern gone on? How old were you when you had your very first HA? Neck Pain: Not applicable Do you have neck pain with HA? Yes No I have a separate (mild / moderate / severe) neck pain not related to HA Neck pain with HA is (circle one) less / equally / more severe than HA. If neck pain is equal to or worse than HA, it has been this way for weeks / months / years? (circle one) Were you neck pain free before this pattern? Yes No If no, please explain: Short Lasting Headaches: Not applicable Do you have a pattern of multiple headaches in a day with complete pain freedom in between each headache? Yes No If yes, please describe (how many episodes per day, how long is each episode, when they occur during the day, etc): How many (circle one) weeks / months / years has that pattern been going on? Do you have watery eyes, runny nose, red skin, swollen skin with these episodes (circle all that apply)? Seasonal Headache Pattern: Not applicable Does your HA always start at a certain time of year? Yes No If yes, what is that HA pattern? (eg, Oct to Jan, etc.) How long have you had that pattern? Outside of that pattern are you completely HA free? Yes No If no, how is your other HA pattern different from your seasonal HA?

2 Headache Timing: Is this HA waking you in the middle of the night? Yes No If yes, how many days a (circle one) week / month does it wake you? Between what hours does the HA wake you? How many (circle one) weeks / months / years has it woken you? When it wakes you, the HA pain is (circle one) Mild Moderate Severe With the HA that wakes you, do you have Watery eyes Runny nose Eye swelling Face swelling (circle all that apply) Red skin on the Right Left Both Sides On days you have HA, do you wake with it? On days you have HA, do you wake with a sore neck? On days you have HA, do you wake with a sore jaw? When does your HA most commonly start? Morning Late Morning Afternoon Late Afternoon Evening Late Evening If you did not treat your HAs would they last more than 4 hrs? Yes No Will your headaches go away in <4 hrs without treatment? How long do your headaches usually last? Dental Diagnoses: Not applicable Do you have dental diagnoses? TMJ Grinding Both Have you had surgery for TMJ? Yes No If yes, Right Left Both Sides When? Is TMJ now controlled? Yes No If no, severity is Mild Moderate Severe If you have bruxism (grinding), it is: Mild Moderate Severe Night-time only Day and Night Do you require a mouth guard? Yes (for TMJ / bruxing / both) No If yes, for how long? If yes: Night only Day and Night When was mouth guard last evaluated? Headache Location: Considering every HA you have had in your life, could you say that nearly 100% of the time they are ONLY on one side? Yes No If, yes: Right Left Where do you feel mild headaches? Forehead: Left Right Both at same time (circle all that apply) Eyes: Left Right Both at same time Temple: Left Right Both at same time Top of head: Left Right Both at same time Back of head: Left Right Both at same time Neck: Left Right Both at same time

3 Where do you feel severe headaches? Forehead: Left Right Both at same time (circle all that apply) Eyes: Left Right Both at same time Temple: Left Right Both at same time Top of head: Left Right Both at same time Back of head: Left Right Both at same time Neck: Left Right Both at same time Please describe the pain of your mild HAs: (circle all the apply) Pressure Ache Burning Stabbing Ice-pick Throbbing Vice-like Boring Average pain level (1-10): Please describe the pain of your severe HAs: (circle all the apply) Are you able to continue your activities with this HA? Pressure Ache Burning Stabbing Ice-pick Throbbing Vice-like Boring Average pain level (1-10): With headaches, do you experience any of the following? (circle all that apply) Yes No Are you able to continue your activities with this HA? Light sensitivity Sound sensitivity Smell sensitivity Nausea Vomiting Vertigo (room spinning) Light-headed Loss of consciousness Watery eyes Runny nose Eye swelling (right / left) Red skin (if yes, where? ) Unable to sit still (eg, pacing / foot tapping) How often do you have the above symptoms with your headaches (eg, rarely, 25% of the time, etc.) Yes No Do you have any of the following that warn you a HA is coming (aka aura )? (circle all that apply) Vision problems Numbness Tingling Weakness Speech problems Light-headed Vertigo (room spinning) Loss of consciousness If you have vision problems, what do you see and is the image white or color? If you have numbness / tingling / weakness, where do you have it? How often (and for how long) do you have vision / sensory symptoms with headaches? Headache Pain Treatment: When you get a HA, do you use any over-the-counter (OTC) medications to treat the HA? If so, please list them: How many total tablets a day of the OTC do you take when you use it? (eg, 6 tablets total a day)

4 How many days of the week do you treat HA with an OTC? How long have you needed to treat the pain like this? (weeks/months/years [please give a number, eg: 6 months]) When you get a HA, do you use any prescribed medications for pain? If so, please list them: How many total tablets a day of the prescribed pain med do you take when you use it? (eg, 6 tablets total a day) How many days of the week do you treat HA with a prescribed pain med? How long have you needed to treat with prescription medication? (weeks/months/years [please give number, eg: 15 years]) Do you treat any other painful conditions (eg, arthritis, low back pain, fibromyalgia, etc.)? If so, what medicines (over the counter and/or prescribed pain meds) do you use? How many days a week and for how long have you treated these other painful conditions? Headache Preventives Treatment: Have you ever been on a medication to prevent HA? If so, please list those used: If you are no longer on a preventive medication, why did you stop? (please list reason for each med tried) Lifestyle Questions: How many meals do you eat a day? How many times do you eat a day? Do you eat at regular times? Yes No Are your meals well-balanced? Yes No How much water do you drink a day? (recommended amount is 64 oz/day or roughly 4 of the 16.9-oz plastic bottles) How much caffeine do you consume a day? (please include coffee, soda, tea, caffeine pills, chocolate) Do you wake up feeling rested? If the answer is no, how long has it been this way? Have you been told you snore? Yes No If yes: Mild Moderate Severe Are you a restless sleeper (are the sheets everywhere when you wake)? Yes No If yes: Mild Moderate Severe Have you ever had a sleep study? Yes No If yes, date/ results: Do you smoke? Yes No If yes, packs a day / week / month? How long? Do you drink alcohol? Yes No If yes, how much and how often? How long? Do you exercise? Yes No If yes, how much, how often? How long?

5 Have you ever had a head injury? Yes No If yes, did you pass out? Yes No If yes, when? How long did you lose consciousness? Have you ever had an infection in your brain or spinal cord? Yes No If yes, please explain: Do you have a history of loss of consciousness? Yes No If yes, please explain: Are you on an oral contraceptive? If so, which one? For how long? Is there a family history of intracranial aneurysm? If yes, which relative? Any death due to rupture? Who in the family has HAs?